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Patient ID (TKS Staff Only)
Have you expericenced and of the following in the past week?
4 = All the time | 3 = Most of the time | 2 = Half of the time | 1 = Some of the time | 0 = 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 sores eyes
4
3
2
1
0
4. Blurred Vision
4
3
2
1
0
5. Poor Vision
4
3
2
1
0
Subtotal of Score Qs 1-5
Have problems with your eyes limited you in performing any of the following during the last week?
4 = All the time | 3 = Most of the time | 2 = Half of the time | 1 = Some of the time | 0 = None of the time | Blank = N/A
6. Reading
4
3
2
1
0
7. Driving at night
4
3
2
1
0
8. Working with a computer or screen
4
3
2
1
0
9. Watching TV
4
3
2
1
0
Subtotal of Score Qs 6-9
Have your eyes felt uncomfortable in any of the following situations during the last week?
4 = All the time | 3 = Most of the time | 2 = Half of the time | 1 = Some of the time | 0 = None of the time | Blank = N/A
10. Windy Conditions
4
3
2
1
0
11. Places or areas with low humidity (very dry)
4
3
2
1
0
12. Areas that are air conditioned
4
3
2
1
0
Subtotal of Score Qs 10-12
Total
Add Subtotals
OSDI Level (Please Leave Blank)
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