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Home » Eye Care Services » Dry Eye » Dry Eye Questionnaire

Dry Eye Questionnaire

Please answer the following questions by checking the box that best represents your answer. Select only one answer per question.

1. Do you experience EYE DISCOMFORT?
a. During a typical day in the past month, how often did your eyes feel discomfort?*
- Never
- Rarely
- Sometimes
- Frequently
- Constantly
b. When your eyes felt discomfort, how intense was this feeling of discomfort at the end of the day, within two hours of going to bed?*
- Never
- Rarely
- Sometimes
- Frequently
- Constantly
2. Do you experience EYE DRYNESS?
a. During a typical day in the past month, how often did your eyes feel dry?*
- Never
- Rarely
- Sometimes
- Frequently
- Constantly
b. When your eyes felt dry, how intense was this feeling of dryness at the end of the day, within two hours of going to bed?*
- Never
- Rarely
- Sometimes
- Frequently
- Constantly
3. Do you have WATERY EYES?
During a typical day in the past month, how often did your eyes look or feel excessively watery?*
- Never
- Rarely
- Sometimes
- Frequently
- Constantly
Score
Your eyes are Normal
You may have Dry Eye Disease
You may have Sjogren's Disease and/or Dry Eye Disease
Want to discuss your score? Leave us your info!
Our team will contact you to discuss your results within 24-48 business hours. You can also call the office and ask them to check up your results as well.
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Urban Eyes

400 Urban Plaza, E-110
Kirkland, WA 98033

Phone: 425-403-2020

Monday: 10:00 AM - 7:00 PM
Tuesday: 10:00 AM - 7:00 PM
Wednesday: 10:00 AM - 7:00 PM
Thursday: 10:00 AM - 7:00 PM
Friday: 10:00 AM - 7:00 PM
Saturday: 10:00 AM - 7:00 PM
Sunday: 11:00 AM - 5:00 PM

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Urban Eyes
400 Urban Plaza, E-110
Kirkland, WA 98033
Phone: 425-403-2020
https://www.myurbaneyes.com

Fax: 425-490-5448

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