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Rexon-Eye Dry Eye Questionnaire 2
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1.
Full Name:
(Nõutav.)
*
2.
Age:
(Nõutav.)
*
3.
Personal code:
(Nõutav.)
*
4.
Did you change your lifestyle based on the guidelines?
(Nõutav.)
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
*
5.
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
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6.
Please rate the condition of your eyes (severity of symptoms):
(Nõutav.)
Severity:
0 = none
Severity:
1 = tolerable
Severity:
2 = uncomfortable
Severity:
3 = annoying
Severity:
4 = unbearable
Dryness, sandy or scratchy sensation
Severity:
0 = none
Severity:
1 = tolerable
Severity:
2 = uncomfortable
Severity:
3 = annoying
Severity:
4 = unbearable
Burning pain / discomfort
Severity:
0 = none
Severity:
1 = tolerable
Severity:
2 = uncomfortable
Severity:
3 = annoying
Severity:
4 = unbearable
Redness
Severity:
0 = none
Severity:
1 = tolerable
Severity:
2 = uncomfortable
Severity:
3 = annoying
Severity:
4 = unbearable
Tearing
Severity:
0 = none
Severity:
1 = tolerable
Severity:
2 = uncomfortable
Severity:
3 = annoying
Severity:
4 = unbearable
Itching
Severity:
0 = none
Severity:
1 = tolerable
Severity:
2 = uncomfortable
Severity:
3 = annoying
Severity:
4 = unbearable
Difficulty opening eyelids in the morning
Severity:
0 = none
Severity:
1 = tolerable
Severity:
2 = uncomfortable
Severity:
3 = annoying
Severity:
4 = unbearable
Blurred vision during the day
Severity:
0 = none
Severity:
1 = tolerable
Severity:
2 = uncomfortable
Severity:
3 = annoying
Severity:
4 = unbearable
Eyes tire easily when reading or working on a computer
Severity:
0 = none
Severity:
1 = tolerable
Severity:
2 = uncomfortable
Severity:
3 = annoying
Severity:
4 = unbearable
Light sensitivity
Severity:
0 = none
Severity:
1 = tolerable
Severity:
2 = uncomfortable
Severity:
3 = annoying
Severity:
4 = unbearable
*
7.
Do your symptoms worsen in certain environments or during certain activities?
(air conditioning, windy conditions, screen time)
(Nõutav.)
No
Yes, please specify:
*
8.
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
*
9.
Do you use eye drops?
(Nõutav.)
No
Yes, please specify:
*
10.
Do you notice a reduction in dry eye syndrome after treatment?
(Nõutav.)
No
Yes, please specify:
*
11.
Please provide your feedback on the Rexon Eye service, treatment effectiveness, and the customer service provided by KSA:
(Nõutav.)
*
12.
Do you give permission to KSA Silmakeskus to use the feedback in different marketing channels (only the first name is mentioned)?
(Nõutav.)
Yes
No
13.
I would like to receive the best offers, eye tips and notifications of new services from KSA Silmakeskus to my e-mail:
jah
*
14.
Do you consent to the processing of your personal data?
(Nõutav.)
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