Dry Eye Self-Test Do you experience sporadic periods of blurred vision? Yes NoPlease rate the FREQUENCY of each of your symptoms on the following scale:*0123Dryness, Grittiness or ScratchinessSoreness or IrritationBurning or WateringEye Fatigue0 = Never1 = Sometimes2 = Often3 = ConstantPlease rate the SEVERITY of each of your symptoms on the following scale:*01234Dryness, Grittiness or ScratchinessSoreness or IrritationBurning or WateringEye Fatigue0 = No Problems1 = Tolerable - not perfect, but not uncomfortable2 = Uncomfortable - irritating, but does not interfere with my day3 = Bothersome - irritating and interferes with my day4 = Intolerable - unable to perform my daily tasksFull Name*Phone*Email*
