Dry Eye Questionnaire

Name: Livingston EyeCare Associates
Address: 10105 Veterans Memorial Drive, Suite 100, Hamburg Township, MI, 48189, US
Telephone: 810-231-5800
Price range: $000 - $300

Please answer the following questions by checking the box that best represents your answer. Select only one answer per question.

1. Do you experience EYE DISCOMFORT?
a. During a typical day in the past month, how often did your eyes feel discomfort?*
- Never
- Rarely
- Sometimes
- Frequently
- Constantly
b. When your eyes felt discomfort, how intense was this feeling of discomfort at the end of the day, within two hours of going to bed?*
- Slight
- Mild
- Moderate
- Severe
- Extreme
2. Do you experience EYE DRYNESS?
a. During a typical day in the past month, how often did your eyes feel dry?*
- Never
- Rarely
- Sometimes
- Frequently
- Constantly
b. When your eyes felt dry, how intense was this feeling of dryness at the end of the day, within two hours of going to bed?*
- Slight
- Mild
- Moderate
- Severe
- Extreme
3. Do you have WATERY EYES?
During a typical day in the past month, how often did your eyes look or feel excessively watery?*
- Never
- Rarely
- Sometimes
- Frequently
- Constantly
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Livingston EyeCare Associates

10105 Veterans Memorial Drive, Suite 100
Hamburg Township, MI 48189

Phone: 810-231-5800
Fax: 810-231-6422

Monday: 10:00 AM - 5:00 PM
Tuesday: 10:00 AM - 6:00 PM
Wednesday: 10:00 AM - 5:00 PM
Thursday: 10:00 AM - 6:00 PM
Friday: 10:00 AM - 5:00 PM
Saturday: Closed
Sunday: Closed

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Livingston EyeCare Associates
10105 Veterans Memorial Drive, Suite 100
Hamburg Township, MI 48189
Phone: 810-231-5800
https://www.livingstoneyecare.com

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1. Do you experience EYE DISCOMFORT?

2. Do you experience EYE DRYNESS?

3. Do you have WATERY EYES?

Livingston EyeCare Associates