Ocular Surface Disease Index© (OSDI©)2
Answer the following 12 questions by clicking the box that best represents each answer.
Once we receive your form, it will be analysed by the Optometrist and you will receive an email with your score. The score indicates the severity of your symptoms. Bear in mind that symptoms don't always relate directly to the severity of the condition.
By submitting this form you agree to be added to our mailing list. You can unsubscribe from this list at any time.
Email address *
Full Name *
Your answer
Have you experienced any of the following during the last week? *
All of the time (4)
Most of the time (3)
Half the time (2)
Some of the time (1)
None of the time (0)
N/A
1. Eyes that are sensitive to light?
2. Eyes that feel gritty?
3. Painful or sore eyes?
4. Blurred vision?
5. Poor vision?
Have problems with your eyes limited you in performing any of the following during the last week? *
All of the time (4)
Most of the time (3)
Half the time (2)
Some of the time (1)
None of the time (0)
N/a
6. Reading?
7. Driving at night?
8. Working with a computer or bank (ATM)?
9. Watching TV?
Have your eyes felt uncomfortable in any of the following situations during the last week? *
All of the time (4)
Most of the time (3)
Half the time (2)
Some of the time (1)
None of the time (0)
N/a
10. Windy conditions?
11. Places or areas with low humidity (very dry)?
12. Areas that are air conditioned?
How long have you been suffering with your eyes?
Your answer
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Additional Terms