Canadian Dry Eye Assessment

Slide 1

Please fill out the Canadian Dry Eye Assessment survey below to determine the severity of your Dry Eye symptoms.

Once finished, we will email you a copy of the completed survey to print off and bring with you to your appointment.

This quick survey will help your Ophthalmologists determine the severity of your Dry Eye symptoms.

Please ensure to total your Score from questions 1-12 at the end of the survey.

You can learn more about Dry Eye here.

Your Name (required)

Your Email (required)

Subject

Patient ID

Date

Please complete this questionnaire. It will help to grade the severity of your Dry Eye symptoms.

Have you experienced any of the following symptoms?

1. Sensitivity to light, during the last week
0 - None of the time1 - Some of the time2 - Half of the time3 - Most of the time4 - All of the time

1. Scoring 0-4

2. Gritty or scratchy sensation, during the last week
0 - None of the time1 - Some of the time2 - Half of the time3 - Most of the time4 - All of the time

2. Scoring 0-4

3. Burning or stinging, during the last week
0 - None of the time1 - Some of the time2 - Half of the time3 - Most of the time4 - All of the time

3. Scoring 0-4

4. Blurred/unclear vision, during the last week
0 - None of the time1 - Some of the time2 - Half of the time3 - Most of the time4 - All of the time

4. Scoring 0-4

5. Vision that fluctuates with blinking, during the last week
0 - None of the time1 - Some of the time2 - Half of the time3 - Most of the time4 - All of the time

5. Scoring 0-4

6. Vision that improves with artificial tears, during the last week
0 - None of the time1 - Some of the time2 - Half of the time3 - Most of the time4 - All of the time

6. Scoring 0-4

7. Tearing/watering, during the last week
0 - None of the time1 - Some of the time2 - Half of the time3 - Most of the time4 - All of the time

7. Scoring 0-4

8. Pain/burning during the night or upon awakening in the morning, during the last week
0 - None of the time1 - Some of the time2 - Half of the time3 - Most of the time4 - All of the time

8. Scoring 0-4

Have you experienced eye irritation while performing any of these activities?

9. Reading or driving a car for long periods, during the last week
0 - None of the time1 - Some of the time2 - Half of the time3 - Most of the time4 - All of the time

9. Scoring 0-4

10. Watching TV/working on a computer for an extended period, during the last week
0 - None of the time1 - Some of the time2 - Half of the time3 - Most of the time4 - All of the time

10. Scoring 0-4

Have your eyes felt uncomfortable in any of the following situations?

11. During wind/air draft exposure, during the last week
0 - None of the time1 - Some of the time2 - Half of the time3 - Most of the time4 - All of the time

11. Scoring 0-4

12. In places with low humidity (heated/cooled places, i.e. planes), during the last week
0 - None of the time1 - Some of the time2 - Half of the time3 - Most of the time4 - All of the time

12. Scoring 0-4

Total Score: Add up the score from questions 1-12

How much do your eyes bother you? Please check box from 1 - 10
1 - Not at all2345 - Moderately678910 - Extremely & Constantly

Please answer the following questions:
A. What brand of artificial tears are you using?

B. How often do you use artificial tears?
Times per day?

Days per week?

C. Are your symptoms better, worse or the same as your last visit?
BetterWorseSame

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