1. Are you using artificial tears often?
   
   Yes  No
   
   
2. Do you feel your use of artificial tears has increased over time?
   
   Yes  No
   
   
3. Have you experienced any of the following symptoms during the last week?
   
   Yes  No
   - Sensitivity to light
   - Eyes that feel gritty
   - Painful or sore eyes
   - Blurred vision
   - Poor vision
   
   
   
4. Have you experienced difficulties performing any of the following during the last week?
   
   Yes  No
   - Reading
   - Driving at night
   - Working on a computer
   - Watching TV
   - Wearing contact lenses
   
   
   
5. Do your dry eyes interfere with any of your leisure or work-related activities?
   
   Yes  No
   
   
6. Would you like to discuss more treatment options with your eye doctor?
   
   Yes  No

If you answered "yes," to any of these questions, make an appointment to tell your eye doctor.

Make sure you take this with you on your eye doctor visit.