Your Name
Phone
Email
1. I normally wear:
Glasses
Contacts
Readers
2. How FREQUENT is your Dryness, Grittiness, or Scratchiness?
Never
Sometimes
Often
Constant
3. How SEVERE is your Dryness, Grittiness, or Scratchiness?
(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
4. How FREQUENT is your Soreness or Irritation?
Never
Sometimes
Often
Constant
5. How SEVERE is your Soreness or Irritation?
(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
6. How FREQUENT is your Burning or Watering?
Never
Sometimes
Often
Constant
7. How SEVERE is your Burning or Watering?
(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
8. How FREQUENT is your Eye Fatigue?
Never
Sometimes
Often
Constant
9. How SEVERE is your Eye Fatigue?
(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
10. Does your dry, itchy eye feeling interfere with recreational and/or work activities?
Most of the time
Sometimes
Not Really
11. Do you use drops or ointment?
Yes
No
12. On average, how many hours of sleep do you get?
3 or less hours of sleep
Between 4-7 hours of sleep
8 or more hours of sleep
Verification
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