University Vision Centre - Dry Eye Questionnaire

  • MM slash DD slash YYYY
  • How often do you have these eye problems?

  • Are your eyes sensitive to these conditions?

  • How often do you use these medications?

  • Have you been diagnosed with any of these conditions?

  • Other Conditions

  • If your score is 30 or higher, or you suspect you may have Dry Eye Syndrome, review your symptoms with your doctor so that she can provide treatment options. Hit "Submit" to send these results directly to your doctor.