Dry Eye Questionnaire

Please take a moment to answer the questions below so that we can gather some basic information regarding your dry eye symptoms:

Medical Questionnaire

Please fill out the following form to help us understand your physical condition.

During a typical day in the past month, how often did your eyes feel discomfort?
When your eyes feel discomfort, how intense was this feeling of discomfort at the end of the day, within two hours of going to bed?
During a typical day in the past month, how often did your eyes feel dry?
When your eyes feel dry, how intense was this feeling of dryness at the end of the day, within two hours of going to bed?
During a typical day in the past month, how often did your eyes look or feel excessively watery?

Thanks! We have received your responses. Dr. Manji will review your symptoms with you during your eye exam.