| 1. Have you experienced any of the following during the last week? | ||||||
| All of the time | Most of the time | Half of the time | Some of the time | None of the time | ||
| 1) Eyes that are sensitive to light? | 4 | 3 | 2 | 1 | 0 | |
| 2) Eyes that feel gritty? | 4 | 3 | 2 | 1 | 0 | |
| 3) Painful or sore eyes? | 4 | 3 | 2 | 1 | 0 | |
| 4) Blurred vision? | 4 | 3 | 2 | 1 | 0 | |
| 5) Poor vision? | 4 | 3 | 2 | 1 | 0 | |
| 2. Have problems with your eyes limited you in performing any of the following during the last week? | ||||||
| All of the time | Most of the time | Half of the time | Some of the time | None of the time | ||
| 6) Reading? | 4 | 3 | 2 | 1 | 0 | N/A |
| 7) Driving? | 4 | 3 | 2 | 1 | 0 | N/A |
| 8) Working with a computer or bank machine(ATM)? | 4 | 3 | 2 | 1 | 0 | N/A |
| 9) Watching TV? | 4 | 3 | 2 | 1 | 0 | N/A |
| 3. Have your eyes felt uncomfortable in any of the following situations during the last week? | ||||||
| All of the time | Most of the time | Half of the time | Some of the time | None of the time | ||
| 10) Windy conditions? | 4 | 3 | 2 | 1 | 0 | N/A |
| 11) Places or areas with low humidity (very dry)? | 4 | 3 | 2 | 1 | 0 | N/A |
| 12) Areas that are air conditioned? | 4 | 3 | 2 | 1 | 0 | N/A |