Dry Eye Questionnaire

Dry Eye Questionnaire

Dry Eye Questionnaire

Dry Eye Questionnaire

Speed II Dry Eye Questionnaire

Dry Eye Disease is more common than most people realize. Please take a moment to carefully complete this questionnaire to better enable your eye care provider to help you.

1 Report the frequency of your symptoms by checking that appropriate box.
Symptoms Never Sometimes Often Constant
Dryness, grittiness or scratchiness
Soreness or irritation
Burning or watering
Eye Fatigue
2 Report the severity of your symptoms by checking that appropriate box.
Symptoms Never Sometimes Often Constant
Dryness, grittiness or scratchiness
Soreness or irritation
Burning or watering
Eye Fatigue
3 Please check if you experienced the above symptoms:
4 Do you use eye drops for lubrication?
5 Do you have fluctuating vision (corrected with blinking)?
6 Have you been told you have blepharitis?
7 Have you been treated for a stye?
8 Have you had any of the following symptoms recently?

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