Rexon-Eye Dry Eye Questionnaire 2 Question Title * 1. Full Name: Question Title * 2. Age: Question Title * 3. Personal code: Question Title * 4. Did you change your lifestyle based on the guidelines? I followed the "screen time" guidelines I monitored my diet I wore sunglasses more often I reduced stress I took dietary supplements, please specify which ones: No changes Question Title * 5. 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 scratchysensation Dryness, sandy or scratchysensation frequency:0 = never Dryness, sandy or scratchysensation frequency:1 = sometimes Dryness, sandy or scratchysensation frequency:2 = often Dryness, sandy or scratchysensation 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 * 6. Please rate the condition of your eyes (severity of symptoms): Severity:0 = none Severity:1 = tolerable 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 = tolerable 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 = tolerable 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 = tolerable Redness Severity:2 = uncomfortable Redness Severity:3 = annoying Redness Severity:4 = unbearable Tearing Tearing Severity:0 = none Tearing Severity:1 = tolerable Tearing Severity:2 = uncomfortable Tearing Severity:3 = annoying Tearing Severity:4 = unbearable Itching Itching Severity:0 = none Itching Severity:1 = tolerable 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 = tolerable 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 = tolerable 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 = tolerable 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 = tolerable Light sensitivity Severity:2 = uncomfortable Light sensitivity Severity:3 = annoying Light sensitivity Severity:4 = unbearable Question Title * 7. Do your symptoms worsen in certain environments or during certain activities?(air conditioning, windy conditions, screen time) No Yes, please specify: Question Title * 8. 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 * 9. Do you use eye drops? No Yes, please specify: Question Title * 10. Do you notice a reduction in dry eye syndrome after treatment? No Yes, please specify: Question Title * 11. Please provide your feedback on the Rexon Eye service, treatment effectiveness, and the customer service provided by KSA: Question Title * 12. Do you give permission to KSA Silmakeskus to use the feedback in different marketing channels (only the first name is mentioned)? Yes No Question Title * 13. I would like to receive the best offers, eye tips and notifications of new services from KSA Silmakeskus to my e-mail: jah Question Title * 14. Do you consent to the processing of your personal data? Nõustun isikuandmete töötlemisega seotud tingimustega. Tehtud
