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Canadian Dry Eye Assesment Form

Please complete this questionnaire. It will help to grade the severity of your Dry Eye symptoms

Name(Required)
Have you experienced any of the following symptoms?
1. Sensitivity to light, during the last week(Required)
2. Gritty or scratchy sensation, during the last week(Required)
3. Burning or stinging, during the last week(Required)
4. Blurred/unclear vision, during the last week(Required)
5. Vision that fluctuates with blinking, during the last week(Required)
6. Vision that improves with artificial tears, during the last week(Required)
7. Tearing/watering, during the last week(Required)
8. Pain/burning during the night or upon awakening in the morning, during the last week(Required)
Have you experienced eye irritation while performing any of these activities?
9. Reading or driving a car for long periods, during the last week(Required)
10. Watching TV/working on a computer for an extended period, during the last week(Required)
Have your eyes felt uncomfortable in any of the following situations?
11. During wind/air draft exposure, during the last week(Required)
12. In places with low humidity (heated/cooled places, i.e. planes), during the last week(Required)
Please do not submit any Protected Health Information (PHI).