1 Patient Details
2 OSDI Questionnaire
3 OSDI Scoring

Patient Information

OSDI Questionnaire

QF.1080-A/24

Please answer the questions given below.

#
Question
Right Eye
Left Eye
1
Do you experience symptoms of dryness in the eye?
2
Is your emotional / reflex tearing reduced in the eye?
3
Do you have itching along the eyelids?
4
Have you been diagnosed to have Sjogren's Syndrome? (Primary, RA, SLE, others)
5
Do you have dry mouth?
6
Do you have small joint pain?
7
Are you on any oral medication for BP, sedatives, depression?
8
Do you wear contact lens?
9
Have you had Lasik /RK/ refractive surgery in the past?
10
Have you been treated for intracranial tumour (brain) in the past?
11
Have you received any radiation therapy to the head face neck region?
12
Have you had any exposure to chemical or fumes to the right/left eye in the past?
13
Have you had conjunctivitis in the past?
14
Have you had paralysis on the either side of your face?
15
Do you work on the computer for more than 4-5 hours in a day?
16
Have you had any bone marrow transplant?
17
Do you have Diabetes?
18
Are you on treatment for Atopy?
19
Are you on treatment for Psoriasis?
20
Are you on Isotretinoin treatment?
21
Are you on Hormone Replacement Therapy? (Estrogen)
22
Are you on topical anti-glaucoma medications for your eye?
23
Do you have thyroid disease?

Ocular Surface Disease Index© (OSDI©)

Scale:  4=Constantly  |  3=Mostly  |  2=Often  |  1=Sometimes  |  0=Never

Have you experienced any of the following during a typical day within the last month?

1. Eyes that are sensitive to light?
2. Vision blurring between blinks (with your refractive correction if needed)?
Symptoms and visual disturbance subscale ⇒ –

Have problems with your eyes limited you in performing any of the following during a typical day within the last month?

3. Driving or being driven at night?
4. Watching TV, or a similar task?
Visual function / tasks subscale ⇒ –

Have your eyes felt uncomfortable in any of the following situations during a typical day within the last month?

5. Windy conditions?
6. Places or areas with low humidity?
Environmental subscale ⇒ –
Total Score: –
Score < 4: Normal  |  Score 4–8: Mild to Moderate dry eye  |  Score > 8: Severe dry eye