Dry Eye Self-Test Do you experience sporadic periods of blurred vision? Yes No Please rate the FREQUENCY of each of your symptoms on the following scale:*0123Dryness, Grittiness or ScratchinessSoreness or IrritationBurning or WateringEye Fatigue 0 = Never 1 = Sometimes 2 = Often 3 = Constant Please rate the SEVERITY of each of your symptoms on the following scale:*01234Dryness, Grittiness or ScratchinessSoreness or IrritationBurning or WateringEye Fatigue 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 Full Name* Phone*Email*
