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Interval EB Eye Symptoms Survey
Hi,
This third survey is the interval survey on EB eye disease.
Please turn your phone sideways to see all the answer choices.
Please answer these 18 questions. It may take 3-5 minutes to complete.
We will send the same set of three surveys again in one week to double check your answers.
Thank you again for your help!
Warm regards, Vicki M. Chen, MD
Tufts Medical Center, Boston, MA
1) Since ______ (date to be announced), have you had any None
eye problems? These are symptoms of a corneal Unable to open eyes
abrasion- please check all that apply Pain
Red eyes
Sensitivity to light Watery eyes Blurred vision Swollen/red eyelids Other
2) Since ______ (date to be announced), how many times 0 have you had a corneal abrasion? Please select a 1
number 2
3 4 5 6 7 8 9 10 1112
3) Since ______ (date to be announced), when you have an 0 abrasion, how does it feel? Please use the pain 1
scale below 2
3 4 5 6 7 8 9 10
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4) Since ______ (date to be announced), how long do your Few hours abrasions usually last (on average)? Please select 1 day
average number of days 2 days
3 days 4 days 5 days 6 days 7 days 8 days 9 days 10 days No abrasions
How many times have you experienced these eye problems in the last month?
5 or more times
4 times 3 times 2 times One time None
5) Eye pain?
6) Unable to open eyes?
7) Red eyes?
8) Sensitivity to lights?
9) Watery eyes?
10) Blurred vision?
11) Symptoms Frequency Score
__________________________________
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How many times have abrasions affected you/your child in the following ways in last month?
5 or more times
4 times 3 times 2 times One time None
12) Difficulty using electronic devices due to glare
13) Difficulty watching TV/computer 14) Difficulty reading normal sized
15) Unable to work or attend school 16) Unable to do regular activities
(driving, playing)
17) Emotional distress/crying 18) Sleeping during the day 19) Squinting or hiding from light 20) Activities of Daily Living Score
__________________________________