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| Does your watery‐eye problem bother you? | Y | N | |
| If it does bother you, does it interfere with your: | Sight? | Y | N |
| Reading? | Y | N | |
| Driving? | Y | N | |
| Mood? | Y | N | |
| Work? | Y | N | |
| If it does interfere, is it: (choose one) | A little? (mild) | ||
| A moderate amount? | |||
| A great deal? (severe) | |||
| Does your watery eye become embarrassing? | Y | N | |
| If it does become embarrassing, is it: (choose one) | A little? (mild) | ||
| A moderate amount? | |||
| A great deal? (severe) |
