Ocular Surface Disease Questionnaire Answer the following 12 questions, and check the number in the box that best represents each answer. Then, fill in boxes A, B, C, D, and E according to the instructions beside each. Name:*Email PhoneHAVE YOU EXPERIENCED ANY OF THE FOLLOWING DURING THE LAST WEEK:1. Eyes that are sensitive to light? All of the time Most of the time Half of the time Some of the time None of the time 2. Eyes that feel gritty? All of the time Most of the time Half of the time Some of the time None of the time 3. Painful or sore eyes? All of the time Most of the time Half of the time Some of the time None of the time 4. Blurred vision? All of the time Most of the time Half of the time Some of the time None of the time 5. Poor vision? All of the time Most of the time Half of the time Some of the time None of the time Subtotal score for answers 1 to 5HAVE PROBLEMS WITH YOUR EYES LIMITED YOU IN PERFORMING ANY OF THE FOLLOWING DURING THE LAST WEEK:6. Reading? All of the time Most of the time Half of the time Some of the time None of the time 7. Driving at night? All of the time Most of the time Half of the time Some of the time None of the time 8. Working with a computer or bank machine (ATM)? All of the time Most of the time Half of the time Some of the time None of the time 9. Watching TV? All of the time Most of the time Half of the time Some of the time None of the time Subtotal score for answers 6 to 9HAVE YOUR EYES FELT UNCOMFORTABLE IN ANY OF THE FOLLOWING SITUATIONS DURING THE LAST WEEK:10. Windy conditions? All of the time Most of the time Half of the time Some of the time None of the time 11. Places or areas with low humidity (very dry)? All of the time Most of the time Half of the time Some of the time None of the time 12. Areas that are air conditioned? All of the time Most of the time Half of the time Some of the time None of the time Subtotal score for answers 10 to 12 Δ
