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Rexon-Eye Dry Eye Questionnaire 1
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1.
Full Name:
(Nõutav.)
*
2.
Age:
(Nõutav.)
*
3.
Personal code:
(Nõutav.)
*
4.
Do you have any known allergies?
(Nõutav.)
No
Yes, please specify:
*
5.
Are you currently taking any medications?
(Nõutav.)
No
Yes, please specify:
*
6.
Do you have any of the following conditions? (You can select several options)
(Nõutav.)
Diabetes
Thyroid disease
Rheumatoid arthritis
Lupus
Sjögren's syndrome
Other autoimmune diseases (please specify):
No
*
7.
Have you previously had any eye surgeries or procedures?
(Nõutav.)
No
Yes, please specify the time and type of
procedure:
*
8.
How long have you had dry eye symptoms?
(Nõutav.)
Less than 1 month
1-3 months
3-6 months
More than 6 months
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9.
Please rate the condition of your eyes (frequency of symptoms):
(Nõutav.)
Frequency:
0 = never
Frequency:
1 = sometimes
Frequency:
2 = often
Frequency:
3 = continuous
Dryness, sandy or scratchy sensation
Frequency:
0 = never
Frequency:
1 = sometimes
Frequency:
2 = often
Frequency:
3 = continuous
Burning pain / discomfort
Frequency:
0 = never
Frequency:
1 = sometimes
Frequency:
2 = often
Frequency:
3 = continuous
Redness
Frequency:
0 = never
Frequency:
1 = sometimes
Frequency:
2 = often
Frequency:
3 = continuous
Tearing
Frequency:
0 = never
Frequency:
1 = sometimes
Frequency:
2 = often
Frequency:
3 = continuous
Itching
Frequency:
0 = never
Frequency:
1 = sometimes
Frequency:
2 = often
Frequency:
3 = continuous
Difficulty opening eyelids in the morning
Frequency:
0 = never
Frequency:
1 = sometimes
Frequency:
2 = often
Frequency:
3 = continuous
Blurred vision during the day
Frequency:
0 = never
Frequency:
1 = sometimes
Frequency:
2 = often
Frequency:
3 = continuous
Eyes tire easily when reading or working on a computer
Frequency:
0 = never
Frequency:
1 = sometimes
Frequency:
2 = often
Frequency:
3 = continuous
Light sensitivity
Frequency:
0 = never
Frequency:
1 = sometimes
Frequency:
2 = often
Frequency:
3 = continuous
*
10.
Please rate the condition of your eyes (severity of symptoms):
(Nõutav.)
Severity:
0 = none
Severity:
1 = acceptable
Severity:
2 = uncomfortable
Severity:
3 = annoying
Severity:
4 = unbearable
Dryness, sandy or scratchy sensation
Severity:
0 = none
Severity:
1 = acceptable
Severity:
2 = uncomfortable
Severity:
3 = annoying
Severity:
4 = unbearable
Burning pain / discomfort
Severity:
0 = none
Severity:
1 = acceptable
Severity:
2 = uncomfortable
Severity:
3 = annoying
Severity:
4 = unbearable
Redness
Severity:
0 = none
Severity:
1 = acceptable
Severity:
2 = uncomfortable
Severity:
3 = annoying
Severity:
4 = unbearable
Tearing
Severity:
0 = none
Severity:
1 = acceptable
Severity:
2 = uncomfortable
Severity:
3 = annoying
Severity:
4 = unbearable
Itching
Severity:
0 = none
Severity:
1 = acceptable
Severity:
2 = uncomfortable
Severity:
3 = annoying
Severity:
4 = unbearable
Difficulty opening eyelids in the morning
Severity:
0 = none
Severity:
1 = acceptable
Severity:
2 = uncomfortable
Severity:
3 = annoying
Severity:
4 = unbearable
Blurred vision during the day
Severity:
0 = none
Severity:
1 = acceptable
Severity:
2 = uncomfortable
Severity:
3 = annoying
Severity:
4 = unbearable
Eyes tire easily when reading or working on a computer
Severity:
0 = none
Severity:
1 = acceptable
Severity:
2 = uncomfortable
Severity:
3 = annoying
Severity:
4 = unbearable
Light sensitivity
Severity:
0 = none
Severity:
1 = acceptable
Severity:
2 = uncomfortable
Severity:
3 = annoying
Severity:
4 = unbearable
*
11.
Do your symptoms worsen in certain environments or during certain activities?
(air conditioning, windy conditions, screen time)
(Nõutav.)
No
Yes, please specify:
*
12.
How many hours a day do you spend in front of a screen (computer, smartphone, TV)?
(Nõutav.)
Less than 2 hours
2-4 hours
4-6 hours
More than 6 hours
*
13.
Do you use eye drops?
(Nõutav.)
No
Yes, please specify:
*
14.
Have you tried any dry eye treatments before?
(Nõutav.)
No
Yes (please specify – eg prescription eye drops, over the counter eye drops, warm compresses, tear duct plugs, other)
*
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.
(Nõutav.)
Yes
No
16.
I wish to receive the best offers, eye care tips, and notifications of new services from
KSA silmakeskus.
No
Yes
*
17.
Do you consent to the processing of your personal data?
(Nõutav.)
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