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27916 Seco Canyon Rd Suite 204 in Santa Clarita

661-748-0198
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Home » Eye Care Services » Dry Eye » Dry Eye Questionnaire

Dry Eye Questionnaire

Please answer the following questions by checking the box that best represents your answer. Select only one answer per question.

1. Do you experience EYE DISCOMFORT?

a. During a typical day in the past month, how often did your eyes feel discomfort?(Required)
b. When your eyes felt discomfort, how intense was this feeling of discomfort at the end of the day, within two hours of going to bed?(Required)

2. Do you experience EYE DRYNESS?

a. During a typical day in the past month, how often did your eyes feel dry?(Required)
b. When your eyes felt dry, how intense was this feeling of dryness at the end of the day, within two hours of going to bed?(Required)

3. Do you have WATERY EYES?

During a typical day in the past month, how often did your eyes look or feel excessively watery?(Required)
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