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.





    0 - None of the time1 - Some of the time2 - Half of the time3 - Most of the time4 - All of the time



    0 - None of the time1 - Some of the time2 - Half of the time3 - Most of the time4 - All of the time



    0 - None of the time1 - Some of the time2 - Half of the time3 - Most of the time4 - All of the time



    0 - None of the time1 - Some of the time2 - Half of the time3 - Most of the time4 - All of the time



    0 - None of the time1 - Some of the time2 - Half of the time3 - Most of the time4 - All of the time



    0 - None of the time1 - Some of the time2 - Half of the time3 - Most of the time4 - All of the time



    0 - None of the time1 - Some of the time2 - Half of the time3 - Most of the time4 - All of the time



    0 - None of the time1 - Some of the time2 - Half of the time3 - Most of the time4 - All of the time



    0 - None of the time1 - Some of the time2 - Half of the time3 - Most of the time4 - All of the time



    0 - None of the time1 - Some of the time2 - Half of the time3 - Most of the time4 - All of the time



    0 - None of the time1 - Some of the time2 - Half of the time3 - Most of the time4 - All of the time



    0 - None of the time1 - Some of the time2 - Half of the time3 - Most of the time4 - All of the time




    1 - Not at all2345 - Moderately678910 - Extremely & Constantly





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