1. Report the type of SYMPTOMS you experience and when they occur:

Dryness, Grittiness or Scratchiness

At this timeNot at this timeWithin past 72 hoursNot within past 72 hoursWithin past 3 monthsNot within past 3 months

Soreness or Irritation

At this timeNot at this timeWithin past 72 hoursNot within past 72 hoursWithin past 3 monthsNot within past 3 months

Burning or Watering

At this timeNot at this timeWithin past 72 hoursNot within past 72 hoursWithin past 3 monthsNot within past 3 months

Eye Fatigue

At this timeNot at this timeWithin past 72 hoursNot within past 72 hoursWithin past 3 monthsNot within past 3 months

2. Report the FREQUENCY of your symptoms using the rating list below:

0 = Never
1 = Sometimes
2 = Often
3 = Constant

Dryness, Grittiness or Scratchiness

0123

Soreness or Irritation

0123

Burning or Watering

0123

Eye Fatigue

0123

3. Report the SEVERITY of your symptoms using the rating list below:

0 = No Problems
1 = Tolerable - not perfect, but not uncomfortable
2 = Uncomfortable - irritating, but does not interfere with my day
3 = Bothersome - irritating and interferes with my day
4 = Intolerable - unable to perform my daily tasks

Dryness, Grittiness or Scratchiness

0123

Soreness or Irritation

0123

Burning or Watering

0123

Eye Fatigue

0123

4. Do you use eye drops for lubrication?

YesNo

how often?

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New or returning patient?

YesNo

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