Dry Eye Disease Self Test
Please complete the following symptom score test form and give it to your doctor. Make an initial assessment of your dry eye condition. Based on the questions in the table, choose the closest answer and end up with a total score.
What is the severity of the following problems? Dong Nuo, Ocular Surface and Corneal Diseases, Xiamen Eye Center, Xiamen University
None
Occasionally
Frequently
Constantly
Eye
Red (congested)
0
3
4
5
Foreign body sensation
0
3
4
5
itchiness
0
3
4
5
Excess moisture
0
3
4
5
Burning sensation
0
3
4
5
Excessive mucus
0
3
4
5
Discharge from the inner canthus
0
3
4
5
Blurred vision (improves after blinking)
0
3
4
5
Visual fatigue
0
3
4
5
dry eyes
0
3
4
5
Astringent
0
3
4
5
Are you particularly sensitive to the following?
Smoke
0
3
4
5
Light
0
3
4
5
Air pollution
0
3
4
5
wind
0
3
4
5
air conditioning
0
3
4
5
Contact lenses
0
3
4
5
computer
0
3
4
5
Do you regularly use the following medications?
Antidepressants
0
3
4
5
Anti-congestants
0
3
4
5
Antihypertensive drugs
0
3
4
5
Artificial tears
0
3
4
5
Hormones
0
3
4
5
Oral contraceptives
0
3
4
5
Diuretics
0
3
4
5
Stomach ulcer medicine
0
3
4
5
Sedatives
0
3
4
5
Have you ever been diagnosed with
Yes
No
Thyroid disease
2
0
Rheumatoid arthritis
2
0
Asthma
2
0
Diabetes
2
0
Glaucoma
2
0
Hemorrhoids
2
0
Is it over 50 years old?
5
0
Have a history of discomfort with contact lenses
4
0
Any prolonged menstruation
5
0
Is there eye tension
4
0
Is there excessive blinking
4
0
Symptom Score Test Scale > 30 for dry eye