Dry Eye Questionnaire Please answer the following questions by checking the box that best represents your answer. Select only one answer per question. 1. Do you experience EYE DISCOMFORT?a. During a typical day in the past month, how often did your eyes feel discomfort?* Never Rarely Sometimes Frequently Constantly b. When your eyes felt discomfort, how intense was this feeling of discomfort at the end of the day, within two hours of going to bed?* Never Rarely Sometimes Frequently Constantly 2. Do you experience EYE DRYNESS?a. During a typical day in the past month, how often did your eyes feel dry?* Never Rarely Sometimes Frequently Constantly b. When your eyes felt dry, how intense was this feeling of dryness at the end of the day, within two hours of going to bed?* Never Rarely Sometimes Frequently Constantly 3. Do you have WATERY EYES?During a typical day in the past month, how often did your eyes look or feel excessively watery?* Never Rarely Sometimes Frequently Constantly Score Your eyes are Normal You may have Dry Eye DiseaseYou may have Sjogren's Disease and/or Dry Eye DiseaseWant to discuss your score? Leave us your info! Our team will contact you to discuss your results within 24-48 business hours. You can also call the office and ask them to check up your results as well.Name* First Last Email* Phone*
