Dry Eye Disease Quiz | Columbus Ophthalmology Associates

Question 1: What is your age?

Under 18

19 - 39

40 - 59

60+

Question 2: Which of the symptoms below do you experience with your eyes on a recurring basis? Please check all that apply.

Question 3: Do any of the above symptoms affect the following? Please check all that apply.

Driving

Reading

Watching TV

Using a computer, smartphone or tablet

Question 4: How often do your eyes bother you?

Rarely

Sometimes

Often

Constantly

Question 5: How severe would you rate the symptoms above, on average?

No problems

Tolerable (not perfect, but not uncomfortable)

Uncomfortable (irritating but doesn’t interfere with my day)

Bothersome (irritating and interferes with my day)

Intolerable (unable to perform daily tasks)

Question 6: Do your dry eyes seem to be getting worse?

Yes

No

Question 7: Would you be interested in scheduling a consultation with a dry eye specialist to schedule a detailed dry eye diagnostic exam?

Yes, please contact me!

Maybe down the road

No

Finalize Your Evaluation

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Suffering With Dry and Irritated Eyes?

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