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University Vision Centre – Dry Eye Questionnaire
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2017-07-06T01:14:26+00:00
University Vision Centre - Dry Eye Questionnaire
Name
First
Last
Date
MM slash DD slash YYYY
How often do you have these eye problems?
Redness
Never: 0
Sometimes: 3
Frequently: 4
Always: 5
Sandy or Gritty Sensation
Never: 0
Sometimes: 4
Frequently: 5
Always: 6
Itching
Never: 0
Sometimes: 3
Frequently: 4
Always: 5
Excess Watering
Never: 0
Sometimes: 3
Frequently: 4
Always: 5
Burning
Never: 0
Sometimes: 4
Frequently: 5
Always: 6
Excess Mucous
Never: 0
Sometimes: 3
Frequently: 4
Always: 5
Blurred Vision (Corrected by blinking)
Never: 0
Sometimes: 4
Frequently: 5
Always: 6
Total Score for Eye Problem Section
Are your eyes sensitive to these conditions?
Smoke
Never: 0
Sometimes: 2
Frequently: 3
Always: 4
Light
Never: 0
Sometimes: 2
Frequently: 3
Always: 4
Air Pollution
Never: 0
Sometimes: 2
Frequently: 3
Always: 4
Wind
Never: 0
Sometimes: 2
Frequently: 3
Always: 4
Computer Screens
Never: 0
Sometimes: 2
Frequently: 3
Always: 4
Heaters
Never: 0
Sometimes: 2
Frequently: 3
Always: 4
Air Conditioning
Never: 0
Sometimes: 2
Frequently: 3
Always: 4
Contact Lenses
Never: 0
Sometimes: 2
Frequently: 3
Always: 4
Total Score for Sensitivity Section
How often do you use these medications?
Anti-Depressants
Never: 0
Sometimes: 1
Frequently: 2
Always: 3
Redness Reducing Eye Drops
Never: 0
Sometimes: 1
Frequently: 2
Always: 3
Decongestants
Never: 0
Sometimes: 1
Frequently: 2
Always: 3
Antihistamines
Never: 0
Sometimes: 1
Frequently: 2
Always: 3
Blood Pressure Medication
Never: 0
Sometimes: 3
Frequently: 4
Always: 3
Artificial Tears (lubricating drops)
Never: 0
Sometimes: 1
Frequently: 2
Always: 3
Hormones
Never: 0
Sometimes: 1
Frequently: 2
Always: 3
Oral Contraceptives
Never: 0
Sometimes: 1
Frequently: 2
Always: 3
Diuretics
Never: 0
Sometimes: 1
Frequently: 2
Always: 3
Ulcer Medications
Never: 0
Sometimes: 1
Frequently: 2
Always: 3
Tranquilizers
Never: 0
Sometimes: 1
Frequently: 2
Always: 3
Beta Blockers
Never: 0
Sometimes: 1
Frequently: 2
Always: 3
Total Score for Medications Section
Have you been diagnosed with any of these conditions?
Thyroid Abnormalities
No: 0
Yes: 2
Rheumatoid Arthritis
No: 0
Yes: 2
Asthma
No: 0
Yes: 2
Diabetes
No: 0
Yes: 2
Glaucoma
No: 0
Yes: 2
Lupus
No: 0
Yes: 2
Total Score for Diagnoses Section
Other Conditions
Are you over 50 years of age?
No: 0
Yes: 5
Are you post-menopausal?
No: 0
Yes: 5
Do you get eye strain?
No: 0
Yes: 4
Do you blink your eyes excessively?
No: 0
Yes: 4
Total Score for Other Conditions Section
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.
Your Total Score
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