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Dry Eye Assessment

Office Hours

Monday 8:00am to 6:00pm
Tuesday 10:00am to 7:00pm
Wednesday 8:00am to 3:00pm
Thursday 10:00am to 7:00pm
Friday 8:00am to 3:00pm
Saturday 8:00am to 12:00pm

3027 English Rows Ave. Suite 209

Naperville, IL 60564

PHONE: 630.922.2661
EMAIL: contactus@englishrow...

Ocular Surface Disease Index (OSDI) Questionnaire

Please fill out this form as it is directly related to Dry Eye Treatment

Name
Prefix First Last Suffix
Date
MM slash DD slash YYYY
Email
Phone
Please answer the following 12 questions.
Have you experienced any of the following in the past week?
1. Eyes that are sensitive to light?
- All of the time
- Most of the time
- Half of the time
- Some of the time
- None of the time
2. Eyes that feel gritty?
- All of the time
- Most of the time
- Half of the time
- Some of the time
- None of the time
3. Painful or Sore Eyes?
- All of the time
- Most of the time
- Half of the time
- Some of the time
- None of the time
4. Blurred vision?
- All of the time
- Most of the time
- Half of the time
- Some of the time
- None of the time
5. Poor vision?
- All of the time
- Most of the time
- Half of the time
- Some of the time
- None of the time
Have you had problems with your eyes which limited you in performing any of the following during the last week?
6. Reading
- All of the time
- Most of the time
- Half of the time
- Some of the time
- None of the time
7. Driving at night?
- All of the time
- Most of the time
- Half of the time
- Some of the time
- None of the time
8. Working with a computer or bank ATM machine?
- All of the time
- Most of the time
- Half of the time
- Some of the time
- None of the time
9. Watching TV?
- All of the time
- Most of the time
- Half of the time
- Some of the time
- None of the time
Have your eyes felt uncomfortable in any of the following situations during the last week?
10. Windy Conditions?
- All of the time
- Most of the time
- Half of the time
- Some of the time
- None of the time
11. Places or areas with low humidity (very dry)?
- All of the time
- Most of the time
- Half of the time
- Some of the time
- None of the time
12. Areas that are air conditioned?
- All of the time
- Most of the time
- Half of the time
- Some of the time
- None of the time
To ensure that you are a real person, please type the words in the box below.

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English Rows Eye Care

3027 English Rows Ave.
Suite 209
Naperville, IL 60564

PHONE
630.922.2661
EMAIL
contactus@englishrowseyecare.com

Convenient Office Hours

Monday 8:00am to 6:00pm
Tuesday 10:00am to 7:00pm
Wednesday 8:00am to 3:00pm
Thursday 10:00am to 7:00pm
Friday 8:00am to 3:00pm
Saturday 8:00am to 12:00pm

Our Services

Contact Lens
Dry Eye Treatment Center
Optical Services
State of the Art Technology
Ocular Disease
Ocular Trauma and Emergencies
Pediatric Vision Care

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