GO-眼表疾病指数评分
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姓名：性别：出生日期
电话家庭地址省市填写本问卷日期第几次就诊
以下由主治大夫填写
请在每题相应的序号前打√
1. 过去一周中，是否有对光线敏感症状？
Have you experienced that the eyes are sensitive to light during the last week?
（1）总是出现。All of the time.
（2）大部分时间出现。Most of the time.
（3）一半时间出现。Half of the time.
（4）偶尔出现。Some of the time.
（5）没有出现。None of the time.
2. 过去一周中，眼睛是否出现异物感？
Have you experienced that the eyes feel gritty during the last week?
（1）总是出现。All of the time.
（2）大部分时间出现。Most of the time.
（3）一半时间出现。Half of the time.
（4）偶尔出现。Some of the time.
（5）没有出现。None of the time.
3. 过去一周中，眼睛是否感觉疼痛或发酸？
Have you experienced painful or sore eyes during the last week?
（1）总是出现。All of the time.
（2）大部分时间出现。Most of the time.
（3）一半时间出现。Half of the time.
（4）偶尔出现。Some of the time.
（5）没有出现。None of the time.
4. 过去一周中，眼睛是否出现看东西模糊的情况？
Have you experienced blurred vision during the last week?
（1）总是出现。All of the time.
（2）大部分时间出现。Most of the time.
（3）一半时间出现。Half of the time.
（4）偶尔出现。Some of the time.
（5）没有出现。None of the time.
5. 过去一周，是否出现视力降低的情况？
Have you experienced poor vision during the last week?
（1）总是出现。All of the time.
（2）大部分时间出现。Most of the time.
（3）一半时间出现。Half of the time.
（4）偶尔出现。Some of the time.
（5）没有出现。None of the time.
6. 过去一周中，眼睛不舒服是否对看书有影响？
Have the problems with your eyes limited you reading book during the last week?
（1）一直有影响。All of the time.
（2）大部分时间受影响。Most of the time.
（3）一半时间受影响。Half of the time.
（4）偶尔受影响。Some of the time.
（5）没有影响。None of the time.
（6）这种情况不适用。
7. 在过去一周中，夜间开车用眼时是否受影响？
Have problems with your eyes limited you driving at night during the last week?
（1）一直有影响。All of the time.
（2）大部分时间受影响。Most of the time.
（3）一半时间受影响。Half of the time.
（4）偶尔受影响。Some of the time.
（5）没有影响。None of the time.
（6）这种情况不适用。
8. 过去一周中，眼睛不适对使用电脑、看手机有影响吗？
Have problems with your eyes limited you working with a computer or smartphone during the last week?
（1）总是受影响。All of the time.
（2）大部分时间受影响。Most of the time.
（3）一半时间受影响。Half of the time.
（4）偶尔受影响。Some of the time.
（5）没有影响。None of the time.
（6）这种情况不适用。
9. 在过去一周中，眼睛不适影响看电视吗？
Have problems with your eyes limited you watching TV during the last week?
（1）总是受影响。All of the time.
（2）大部分时间受影响。Most of the time.
（3）一半时间受影响。Half of the time.
（4）偶尔受影响。Some of the time.
（5）没有影响。None of the time.
（6）这种情况不适用。
10. 过去一周中，刮风天气会引起眼睛不适吗？
Have your eyes felt uncomfortable in windy conditions during the last week?
（1）总是不适。All of the time.
（2）大部分时间不适。Most of the time.
（3）一半时间不适。Half of the time.
（4）偶尔不适。Some of the time.
（5）没有不适。None of the time.
（6）这种情况不适用。
11. 在过去一周中，在相对干燥得地方会让您眼睛不舒服吗？
Have your eyes felt uncomfortable in the place or areas with low humidity （very dry）during the last week？
（1）总是不适。All of the time.
（2）大部分时间不适。Most of the time.
（3）一半时间不适。Half of the time.
（4）偶尔不适。Some of the time.
（5）没有不适。None of the time.
（6）这种情况不适用。
12. 过去一周中，呆在有空调的房间眼睛会感觉不舒服吗？
Have your eyes felt uncomfortable in the areas that are air conditioned during the last week?
（1）总是不适。All of the time.
（2）大部分时间不适。Most of the time.
（3）一半时间不适。Half of the time.
（4）偶尔不适。Some of the time.
（5）没有不适。None of the time.
（6）这种情况不适用。