Name:
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How long have you experienced dry eye disease?
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Have you experienced any of the following during the last week?

Eyes that are sensitive to light?




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Eyes that feel gritty?




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Painful or sore eyes?




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Blurred vision?




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Poor vision?




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

Reading?





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Driving at night?





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Working with a computer or bank machine (ATM)?





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Watching TV?





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Have your eyes felt uncomfortable in any of the following situations during the last week?

Windy conditions?





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Places or areas with low humidity (very dry)?





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Areas that are air conditioned?





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