Full Name

Email *

Phone

Report the type of SYMPTOMS you experience and when they occur:

Dryness, Grittiness or Scratchiness at the visit

Yes

Dryness, Grittiness or Scratchiness Within past 72 hours

Yes

Any Dryness, Grittiness or Scratchiness Within past 3 months

Yes

Any Soreness or Irritation at the time of the visit

Yes

Soreness or Irritation within 72 hours

Yes

Soreness or Irritation within past 3 months

Yes

Any burning of watering at the time of the visit

Yes

Any burning of watering within past 72 hours

Yes

Burning or Watering within past 3 months

Yes

Any eye Fatique at the time of the visit

Yes

Eye Fatigue within 72 hours

Yes

Eye Fatigue within past 3 months

Yes

Report the FREQUENCY of your symptoms using the rating list below:

0 = Never 1 = Sometimes 2 = Often 3 = Constant

Dryness, Grittiness or Scratchiness

0
1
2
3
No elements found. Consider changing the search query.
List is empty.

Soreness or Irritation

0
1
2
3
No elements found. Consider changing the search query.
List is empty.

Eye Fatigue

0
1
2
3
No elements found. Consider changing the search query.
List is empty.

Burning or Watering

0
1
2
3
No elements found. Consider changing the search query.
List is empty.

Report the SEVERITY of your symptoms using the rating 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

Did you experience any Dryness, Grittiness or Scratchiness.

0
1
2
3
4
No elements found. Consider changing the search query.
List is empty.

Any Soreness or Irritation?

0
1
2
3
4
No elements found. Consider changing the search query.
List is empty.

Any Burning or Watering?

0
1
2
3
4
No elements found. Consider changing the search query.
List is empty.

Any Eye Fatigue?

0
1
2
3
4
No elements found. Consider changing the search query.
List is empty.

Do you use eye drops for lubrication?

Yes