Dry Eye Self Evaluation DRY EYE SELF-EVALUATION Thank you for your interest. Dry eye disease is one of the most frequent reasons that patients visit eye doctors. Please complete this dry eye disease self-evaluation to determine if you might be suffering from dry eye. Name * First Name Last Name Email * example@example.com Phone Number * Please enter a valid phone number. Check any of the below symptoms you have: Occasional blurring of vision, especially with reading or computer work Redness Burning/Pain Itching Light Sensitivity Excess tearing / watering eyes Tired eyes Contact lens discomfort Feeling of sand or grit in the eye Report the FREQUENCY of symptoms you are experiencing using the following numbering system: 0= Never, 1= Sometimes, 2= Often, 3= Constant Dryness, Grittiness or Scratchiness Please Select 0 1 2 3 Soreness or Irritation Please Select 0 1 2 3 Burning or Watering Please Select 0 1 2 3 Do you use (check all that apply): Over-the-counter drops to treat your dry eyes Prescription eye drops for dry eyes Eye drops for glaucoma Eye drops for allergies Nutritional supplements for eyes Have you had surgery for: Cataracts Glaucoma Refractive surgery (LASIK) Submit Should be Empty: