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.

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HAVE YOU EXPERIENCED ANY OF THE FOLLOWING DURING THE LAST WEEK:

1. Eyes that are sensitive to light?

2. Eyes that feel gritty?

3. Painful or sore eyes?

4. Blurred vision?

5. Poor vision?

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?

7. Driving at night?

8. Working with a computer or bank machine (ATM)?

9. Watching TV?

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?

11. Places or areas with low humidity (very dry)?

12. Areas that are air conditioned?

Subtotal score for answers 10 to 12

Ocular Surface Disease Questionnaire

Peters Family Eyecare