Ocular Surface Disease (Dry Eye) Questionnaire Date MM slash DD slash YYYY Name(Required) First Last Date of Birth MM slash DD slash YYYY Phone(Required)Email How FREQUENTLY do you experience the following dry eye symptoms? Dryness, Grittiness or Scratchiness Never (0) Sometimes (1) Often (2) Constant (3) Soreness or Irritation Never (0) Sometimes (1) Often (2) Constant (3) Burning or Watering Never (0) Sometimes (1) Often (2) Constant (3) Eye Fatigue Never (0) Sometimes (1) Often (2) Constant (3) How SEVERE are your dry eye symptoms?Dryness, Grittiness or Scratchiness No problems (0) Tolerable – not perfect but not uncomfortable (1) Uncomfortable – irritating but does not interfere with my day (2) Bothersome – irritating and interferes with my day (3) Intolerable – unable to perform my daily tasks (4) Soreness or Irritation No problems (0) Tolerable – not perfect but not uncomfortable (1) Uncomfortable – irritating but does not interfere with my day (2) Bothersome – irritating and interferes with my day (3) Intolerable – unable to perform my daily tasks (4) Burning or Watering No problems (0) Tolerable – not perfect but not uncomfortable (1) Uncomfortable – irritating but does not interfere with my day (2) Bothersome – irritating and interferes with my day (3) Intolerable – unable to perform my daily tasks (4) Eye Fatigue No problems (0) Tolerable – not perfect but not uncomfortable (1) Uncomfortable – irritating but does not interfere with my day (2) Bothersome – irritating and interferes with my day (3) Intolerable – unable to perform my daily tasks (4) Total SPEED score Δ
