DRY EYE QUESTIONNAIRE (DEQ-5) Name Phone Number Email What is your age group? Under 18 18-29 30-39 40-59 60+ 1. Questions about 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? NEVER HAVE IT NOT AT ALL INTENSE VERY INTENSE 2. Questions about 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? NEVER HAVE IT NOT AT ALL INTENSE VERY INTENSE 3. Questions about 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 Time is Up!Copyright © Begley & Chalmers 2018, all rights reserved Licensed by Sight Sciences 06531, A
