Please respond to each of the 12 questions --- do not leave any blank. If any of the questions numbered 6 to 12 do not apply to you, please select "N/A".

After you have entered all your answers, you will be shown a score that will guide you in determining whether you might benefit from a dry eye evaluation in the University Eye Center's Dry Eye Clinic.


Have you experienced the following during the last week?

Eyes that are sensitive to light?


1/12

Have you experienced the following during the last week?

Eyes that feel gritty?


2/12

Have you experienced the following during the last week?

Painful or sore eyes?


3/12

Have you experienced the following during the last week?

Blurred vision?


4/12

Have you experienced the following during the last week?

Poor vision?


5/12

Have problems with your eyes limited you in performing the following during the last week?

Reading?


6/12

Have problems with your eyes limited you in performing the following during the last week?

Driving at night?


7/12

Have problems with your eyes limited you in performing the following during the last week?

Working at a computer or bank machine (ATM)?


8/12

Have problems with your eyes limited you in performing the following during the last week?

Watching TV?


9/12

Have your eyes felt uncomfortable in the following situation during the last week?

Windy conditions?


10/12

Have your eyes felt uncomfortable in the following situation during the last week?

Places or areas with low humidity (very dry)?


11/12

Have your eyes felt uncomfortable in the following situation during the last week?

Areas that are air conditioned?


12/12

Dry Eye Assessment

Your score is .

Patients with a score greater than 13 may benefit from a Dry Eye examination at the Meredith W. Morgan Dry Eye Clinic.

To schedule a Dry Eye exam, ask your Optometry clinician to refer you to the Dry Eye Clinic at your next appointment, or call (510) 642-2020 and ask to be seen in our Dry Eye Clinic.