• Report the FREQUENCY of dry eye symptoms you are experiencing by checking Never, Sometimes, Often or Constant using the numbering system below:

    0 = Never, 1 = Sometimes, 2 = Often, 3 = Constant
  • Report the SEVERITY of your symptoms using the ratings list below:

    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
  • Activities

  • Have you been told that you have blepharitis or have you been treated for a stye?

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