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. 2016 Jun 1;10:1015–1021. doi: 10.2147/OPTH.S99620

Table S1.

Newly designed Dry Eye Symptom Questionnaire

Three-part questionnaire
A Symptom frequency and severity scores for dryness
  1) Do you feel dryness in your eyes?
  2) Are your eyes uncomfortable?
  3) Do you experience a foreign body sensation in your eyes?
  4) Do you have any pain in your eyes?
  5) Do you feel any eyestrain?
  6) Do you have any discomfort in your eyes?
  7) Are your eyes bloodshot?
  8) Do you have any itching in your eyes?
  9) Do you have any difficulty opening your eyes?
10) Do you have any irritation in your eyes?
11) Do your eyes feel heavy?
12) If you have any other symptoms, please write it in the parentheses beneath and circle the frequency
Total (1–12): () – A
B Symptom frequency severity scores for visual disturbance
13) Do you have hazy vision?
14) Do you have any glare?
15) While reading, do your dry eye symptoms worsen, and it becomes hard to continue reading?
16) While driving, do your dry eye symptoms worsen, and it becomes difficult to drive?
17) While operating the computer, do your dry eye symptoms worsen, and it becomes difficult to continue?
18) While watching TV or movies, do your dry eye symptoms worsen, and it becomes difficult to watch?
19) Do you have any after-images?
20) Do you think that blinking affects your sight?
21) Can you keep your eyes open without blinking for 10 seconds or more?
Total (13–21): () – B
C Symptom frequency severity scores for environmental and lifestyle factors: Do your dry eye symptoms worsen?
22) When the wind is strong?
23) When it is dry in winter or summer?
24) When the air conditioning is on?
25) While flying?
26) When you feel stressed in daily life?
27) After alcohol consumption?
28) When you smoke or are exposed to someone smoking next to you?
29) When you are wearing contact lenses?
Total (22–29): () – C

Notes: Of the 29 questions, 1 through 29, except for 21, were classified into the following five stages: 4, always; 3, often; 2, occasionally; 1, rarely; and 0, never. Question 21 was classified into the following five stages: 4, not possible; 3, with difficulty; 2, moderately possible; 1, probable; and 0, not a problem.