Rexon-Eye Dry Eye Questionnaire 1 Question Title * 1. Full Name: Question Title * 2. Age: Question Title * 3. Personal code: Question Title * 4. Do you have any known allergies? No Yes, please specify: Question Title * 5. Are you currently taking any medications? No Yes, please specify: Question Title * 6. Do you have any of the following conditions? (You can select several options) Diabetes Thyroid disease Rheumatoid arthritis Lupus Sjögren's syndrome Other autoimmune diseases (please specify): No Question Title * 7. Have you previously had any eye surgeries or procedures? No Yes, please specify the time and type ofprocedure: Question Title * 8. How long have you had dry eye symptoms? Less than 1 month 1-3 months 3-6 months More than 6 months Question Title * 9. Please rate the condition of your eyes (frequency of symptoms): Frequency:0 = never Frequency:1 = sometimes Frequency:2 = often Frequency:3 = continuous Dryness, sandy or scratchy sensation Dryness, sandy or scratchy sensation Frequency:0 = never Dryness, sandy or scratchy sensation Frequency:1 = sometimes Dryness, sandy or scratchy sensation Frequency:2 = often Dryness, sandy or scratchy sensation Frequency:3 = continuous Burning pain / discomfort Burning pain / discomfort Frequency:0 = never Burning pain / discomfort Frequency:1 = sometimes Burning pain / discomfort Frequency:2 = often Burning pain / discomfort Frequency:3 = continuous Redness Redness Frequency:0 = never Redness Frequency:1 = sometimes Redness Frequency:2 = often Redness Frequency:3 = continuous Tearing Tearing Frequency:0 = never Tearing Frequency:1 = sometimes Tearing Frequency:2 = often Tearing Frequency:3 = continuous Itching Itching Frequency:0 = never Itching Frequency:1 = sometimes Itching Frequency:2 = often Itching Frequency:3 = continuous Difficulty opening eyelids in the morning Difficulty opening eyelids in the morning Frequency:0 = never Difficulty opening eyelids in the morning Frequency:1 = sometimes Difficulty opening eyelids in the morning Frequency:2 = often Difficulty opening eyelids in the morning Frequency:3 = continuous Blurred vision during the day Blurred vision during the day Frequency:0 = never Blurred vision during the day Frequency:1 = sometimes Blurred vision during the day Frequency:2 = often Blurred vision during the day Frequency:3 = continuous Eyes tire easily when reading or working on a computer Eyes tire easily when reading or working on a computer Frequency:0 = never Eyes tire easily when reading or working on a computer Frequency:1 = sometimes Eyes tire easily when reading or working on a computer Frequency:2 = often Eyes tire easily when reading or working on a computer Frequency:3 = continuous Light sensitivity Light sensitivity Frequency:0 = never Light sensitivity Frequency:1 = sometimes Light sensitivity Frequency:2 = often Light sensitivity Frequency:3 = continuous Question Title * 10. Please rate the condition of your eyes (severity of symptoms): Severity:0 = none Severity:1 = acceptable Severity:2 = uncomfortable Severity:3 = annoying Severity:4 = unbearable Dryness, sandy or scratchy sensation Dryness, sandy or scratchy sensation Severity:0 = none Dryness, sandy or scratchy sensation Severity:1 = acceptable Dryness, sandy or scratchy sensation Severity:2 = uncomfortable Dryness, sandy or scratchy sensation Severity:3 = annoying Dryness, sandy or scratchy sensation Severity:4 = unbearable Burning pain / discomfort Burning pain / discomfort Severity:0 = none Burning pain / discomfort Severity:1 = acceptable Burning pain / discomfort Severity:2 = uncomfortable Burning pain / discomfort Severity:3 = annoying Burning pain / discomfort Severity:4 = unbearable Redness Redness Severity:0 = none Redness Severity:1 = acceptable Redness Severity:2 = uncomfortable Redness Severity:3 = annoying Redness Severity:4 = unbearable Tearing Tearing Severity:0 = none Tearing Severity:1 = acceptable Tearing Severity:2 = uncomfortable Tearing Severity:3 = annoying Tearing Severity:4 = unbearable Itching Itching Severity:0 = none Itching Severity:1 = acceptable Itching Severity:2 = uncomfortable Itching Severity:3 = annoying Itching Severity:4 = unbearable Difficulty opening eyelids in the morning Difficulty opening eyelids in the morning Severity:0 = none Difficulty opening eyelids in the morning Severity:1 = acceptable Difficulty opening eyelids in the morning Severity:2 = uncomfortable Difficulty opening eyelids in the morning Severity:3 = annoying Difficulty opening eyelids in the morning Severity:4 = unbearable Blurred vision during the day Blurred vision during the day Severity:0 = none Blurred vision during the day Severity:1 = acceptable Blurred vision during the day Severity:2 = uncomfortable Blurred vision during the day Severity:3 = annoying Blurred vision during the day Severity:4 = unbearable Eyes tire easily when reading or working on a computer Eyes tire easily when reading or working on a computer Severity:0 = none Eyes tire easily when reading or working on a computer Severity:1 = acceptable Eyes tire easily when reading or working on a computer Severity:2 = uncomfortable Eyes tire easily when reading or working on a computer Severity:3 = annoying Eyes tire easily when reading or working on a computer Severity:4 = unbearable Light sensitivity Light sensitivity Severity:0 = none Light sensitivity Severity:1 = acceptable Light sensitivity Severity:2 = uncomfortable Light sensitivity Severity:3 = annoying Light sensitivity Severity:4 = unbearable Question Title * 11. Do your symptoms worsen in certain environments or during certain activities?(air conditioning, windy conditions, screen time) No Yes, please specify: Question Title * 12. How many hours a day do you spend in front of a screen (computer, smartphone, TV)? Less than 2 hours 2-4 hours 4-6 hours More than 6 hours Question Title * 13. Do you use eye drops? No Yes, please specify: Question Title * 14. Have you tried any dry eye treatments before? No Yes (please specify – eg prescription eye drops, over the counter eye drops, warm compresses, tear duct plugs, other) Question Title * 15. I confirm that I do not have the following contraindications: pregnancy and breastfeeding, hearing or other implants, I am not a cancer patient, and I have not had eye surgery in the last month. Yes No Question Title * 16. I wish to receive the best offers, eye care tips, and notifications of new services fromKSA silmakeskus. No Yes Question Title * 17. Do you consent to the processing of your personal data? 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