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- Community Outreach & Charity Initiatives
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Home » Dry Eye » Ocular Surface Disease Questionnaire

Ocular Surface Disease Questionnaire

Answer the following 12 questions, and check the number in the box that best represents each answer. Then, fill in boxes A, B, C, D, and E according to the instructions beside each.
Name:*
Email*
Phone
HAVE YOU EXPERIENCED ANY OF THE FOLLOWING DURING THE LAST WEEK:
1. Eyes that are sensitive to light?
- All of the time
- Most of the time
- Half of the time
- Some of the time
- None of the time
2. Eyes that feel gritty?
- All of the time
- Most of the time
- Half of the time
- Some of the time
- None of the time
3. Painful or sore eyes?
- All of the time
- Most of the time
- Half of the time
- Some of the time
- None of the time
4. Blurred vision?
- All of the time
- Most of the time
- Half of the time
- Some of the time
- None of the time
5. Poor vision?
- All of the time
- Most of the time
- Half of the time
- Some of the time
- None of the time
Subtotal score for answers 1 to 5
HAVE PROBLEMS WITH YOUR EYES LIMITED YOU IN PERFORMING ANY OF THE FOLLOWING DURING THE LAST WEEK:
6. Reading?
- All of the time
- Most of the time
- Half of the time
- Some of the time
- None of the time
7. Driving at night?
- All of the time
- Most of the time
- Half of the time
- Some of the time
- None of the time
8. Working with a computer or bank machine (ATM)?
- All of the time
- Most of the time
- Half of the time
- Some of the time
- None of the time
9. Watching TV?
- All of the time
- Most of the time
- Half of the time
- Some of the time
- None of the time
Subtotal score for answers 6 to 9
HAVE YOUR EYES FELT UNCOMFORTABLE IN ANY OF THE FOLLOWING SITUATIONS DURING THE LAST WEEK:
10. Windy conditions?
- All of the time
- Most of the time
- Half of the time
- Some of the time
- None of the time
11. Places or areas with low humidity (very dry)?
- All of the time
- Most of the time
- Half of the time
- Some of the time
- None of the time
12. Areas that are air conditioned?
- All of the time
- Most of the time
- Half of the time
- Some of the time
- None of the time
Subtotal score for answers 10 to 12

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Peters Family Eyecare

219 S Main St
Bryan, OH 43506

Phone: 419-636-3937
Email: pfefrontdesk@gmail.com
(Do not send personal health information by email.)

Monday: 8:00 AM - 5:00 PM
Tuesday: 8:00 AM - 5:00 PM
Wednesday: 8:00 AM - 5:00 PM
Thursday: 8:00 AM - 5:00 PM
Friday: 8:00 AM - 5:00 PM
Saturday: Closed
Sunday: Closed

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Our Team
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Insurance

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Peters Family Eyecare - Located at 219 S Main St, Bryan, OH , 43506. Phone: 419-636-3937 . https://www.petersfamilyeyecare.com

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