CDEA Form

Canadian Dry Eye Assessment (CDEA)

Canadian standard to evaluate the severity and progression of dry eye symptoms.

Name(Required)

First Last

Date(Required)

Have you experienced any of the following symptoms in the last week?(Required)

	0 - None of the time	1 - Some of the time	2 - Half of the time	3 - Most of the time	4 - All of the time
Sensitivity to light
Gritty or scratchy sensation
Burning or stinging
Blurred or unclear vision
Vision that fluctuates with blinking
Vision that improves with artificial tears
Tearing or watering
Pain/burning during the night or upon awakening in the morning

Have you experienced eye irritation while performing any of these activities during the last week?(Required)

Have your eyes felt uncomfortable in any of the following situations during the last week?(Required)

How much do your eyes bother you? Please check a number between 1 - 10(Required)

Are you using artificial tears? If yes, which brand and how often do you use them?(Required)

Is there anything else you would like us to know about your dry eye related issues before you come in to see the specialist?