Today's Date

MM

DD

YYYY

Dryness, Grittiness or Scratchiness *

At this time

Within past 72 hours

Within past 3 months

Not at this time

Not within past 72 hours

Not within past 3 months

Soreness or Irritation *

At this time

Within past 72 hours

Within past 3 months

Not at this time

Not within past 72 hours

Not within past 3 months

Burning or Watering *

At this time

Within past 72 hours

Within past 3 months

Not at this time

Not within past 72 hours

Not within past 3 months

Eye Fatigue *

At this time

Within past 72 hours

Within past 3 months

Not at this time

Not within past 72 hours

Not within past 3 months

Dryness, Grittiness or Scratchiness *

0 – Never

1 – Sometimes

2 – Often

3 – Constant

Soreness or Irritation *

0 – Never

1 – Sometimes

2 – Often

3 – Constant

Burning or Watering *

0 – Never

1 – Sometimes

2 – Often

3 – Constant

Eye Fatigue *

0 – Never

1 – Sometimes

2 – Often

3 – Constant

Dryness, Grittiness or Scratchiness *

0 – No problems

1 – Tolerable

2 – Uncomfortable

3 – Bothersome

4 – Intolerable

Soreness or Irritation *

0 – No problems

1 – Tolerable

2 – Uncomfortable

3 – Bothersome

4 – Intolerable

Burning or Watering

0 – No problems

1 – Tolerable

2 – Uncomfortable

3 – Bothersome

4 – Intolerable

Eye Fatigue *

0 – No problems

1 – Tolerable

2 – Uncomfortable

3 – Bothersome

4 – Intolerable

Do you use eye drops for lubrication? *

Yes

No

Name

First Name

Last Name

Birth Date

MM

DD

YYYY

Sex

Female

Male

Prefer not to say