Dry Eye Assessments

We understand that living with dry eyes can be uncomfortable and frustrating.

Many people experience:

– soreness, stinging, or burning sensations
– eyes that feel gritty, tired, or heavy
– fluctuating or blurred vision
– sensitivity to wind, air conditioning or screens
– needing to use drops frequently for relief

To help us better understand your experience and provide the most effective care, we kindly ask you to complete a short questionnaire below.

About you

Your first name

Your last name

Your email address

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1 of 5 - 0%

Symptom Assessment

How often do you experience the following symptoms with your eyes?

	Never	Sometimes	Frequently	Constantly
Dryness of the eyes
Burning or stinging sensation
Grittiness or sandy feeling
Redness
Sensitivity to light (photophobia)
Blurred or fluctuating vision
Excessive tearing watering of the eyes

2 / 5 - 40%

Impact on Daily Life

How much do your dry eye symptoms interfere with your daily activities?

	Never	Sometimes	Frequently	Constantly
Reading
Driving / Driving at Night
Using Computers / Devices
Watching TV
Outdoor Activities

3 / 5 - 60%

Impact on Daily Life

Do you feel discomfort in any of the following conditions?

	Never	Sometimes	Frequently	Constantly
Windy/Cold Weather
Places or areas with low humidity (very dry)
Areas that are air conditioned
Wearing contact lenses

4 / 5 - 80%

Dry Eye Assessments