1.
Have you experienced any of these symptoms in the past week?
Light-sensitive eyes
A
All the time
B
Most of the time
C
Half of the time
D
A few times
E
Never
Ok ✓
press
Enter
2.
Have you experienced any of these symptoms in the past week?
Itchy eyes
A
All the time
B
Most of the time
C
Half of the time
D
A few times
E
Never
Ok ✓
press
Enter
3.
Have you experienced any of these symptoms in the past week?
Sensitive or sore eyes
A
All the time
B
Most of the time
C
Half of the time
D
A few times
E
Never
Ok ✓
press
Enter
4.
Have you experienced any of these symptoms in the past week?
A blurred vision
A
All the time
B
Most of the time
C
Half of the time
D
A few times
E
Never
Ok ✓
press
Enter
5.
Have you experienced any of these symptoms in the past week?
Weakened vision
A
All the time
B
Most of the time
C
Half of the time
D
A few times
E
Never
Ok ✓
press
Enter
6.
Did problems related to your eyes limit some of these activities over the past week?
Read
A
All the time
B
Most of the time
C
Half of the time
D
A few times
E
Never
Ok ✓
press
Enter
7.
Did problems related to your eyes limit some of these activities over the past week?
Driving at night
A
All the time
B
Most of the time
C
Half of the time
D
A few times
E
Never
Ok ✓
press
Enter
8.
Did problems related to your eyes limit some of these activities over the past week?
Work at the computer or make a transaction at a bank counter
A
All the time
B
Most of the time
C
Half of the time
D
A few times
E
Never
Ok ✓
press
Enter
9.
Did problems related to your eyes limit some of these activities over the past week?
Watch TV
A
All the time
B
Most of the time
C
Half of the time
D
A few times
E
Never
Ok ✓
press
Enter
10.
Did you experience discomfort in your eyes in any of the following situations during the past week?
Windy conditions
A
All the time
B
Most of the time
C
Half of the time
D
A few times
E
Never
Ok ✓
press
Enter
11.
Did you experience discomfort in your eyes in any of the following situations during the past week?
Places or areas with low humidity levels (very dry places)
A
All the time
B
Most of the time
C
Half of the time
D
A few times
E
Never
Ok ✓
press
Enter
12.
Did you experience discomfort in your eyes in any of the following situations during the past week?
Air conditioned places
A
All the time
B
Most of the time
C
Half of the time
D
A few times
E
Never
Ok ✓
press
Enter
Find out if you are suffering from dry eyes!
FIRST NAME
NAME
PHONE NUMBER
EMAIL
Step
0
/
5
↑
↓
Powered by
Formly
Thank you! 1
Your submission has been received!
Oops! Something went wrong while submitting the form.
FR
EN
