Dry Eye Quiz

Suffering With Dry and Irritated Eyes?

Complete the following short self evaluation quiz to help us determine how the Southern Eye Group Dry Eye Clinic can be of most help to you.

Dry Eye Questionnaire

How often do you experience the following symptoms?

Dryness, Grittiness or Scratchiness

Never

Sometimes

Often

Constant

Soreness or Irritation

Never

Sometimes

Often

Constant

Burning or Watering

Never

Sometimes

Often

Constant

Eye Fatigue

Never

Sometimes

Often

Constant

Fluctuating Vision

Never‎

Sometimes‎

Often

Constant

When did you last experience symptoms?

Today

Within the past 3 days

Within the past 3 months

Section

Do you use drops for lubrication?

Yes

No

Section

Have you been told you have Blepharitis?

Yes

No

Section

Have you been treated for a Stye?

Yes

No

Section

Have you had any of these symptoms recently?

Eyelid redness

Crusting around lashes

Lid irritation

None of the above

Finalize Your Evaluation

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