Report the frequency of your symptoms by checking that appropriate circle
(0 = Never, 1 = Sometimes, 2 = Often, 3 = Constant)

Dryness, grittiness or scratchiness

Soreness or irritation

Burning or watering

Eye Fatigue

Report the severity of your symptoms by checking that appropriate box.
(0 = Never, 1 = Mild, 2 = Moderate, 3 = Severe)

Dryness, grittiness or scratchiness

Soreness or irritation

Burning or watering

Eye Fatigue

Please check if you experienced the above symptoms:

Do you use eye drops for lubrication? If so, how often? What brand?

Do you have fluctuating vision (corrected with blinking)?

Have you been told you have blepharitis?

Have you been treated for a stye?

Have you had any of the following symptoms recently?