Dry Eye Self Test - Piedmont Eye Care

Name*

First Last

Email*

Phone*

During a typical day in the past month, how often did your eyes feel discomfort?*

When your eyes felt discomfort, how intense was the discomfort at the end of the day (within two hours of going to bed)?*

During the past month, how often did your eyes feel dry?*

When your eyes felt dry, how intense was the dryness at the end of the day (within two hours of going to bed)?*

During the past month, how often did your eyes look or feel excessively watery?*

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