SPEED Questionnaire

SPEED Questionnaire

Adults Clients Only
Name:*

First NameLast Name
Date:*

MonthDayYear
Date
Gender:*
Date of Birth:*

MonthDayYear
Date
For the Standardized Patient Evaluation of Eye Dryness (SPEED) Questionnaire, please answer the following questions by checking the box that best represents your answer. Select only one answer per questions.

1. A. Report the type of SYMPTOMS you've experienced TODAY:*

Rows	Today: Yes	Today: No
Dryness, Grittiness or Scratchiness
Soreness or Irritation
Burning or Watering
Eye Fatigue

1. B. Report the type of SYMPTOMS you've experienced in the LAST 72 HOURS:*

Rows	Last 72 Hours: Yes	Last 72 Hours: No
Dryness, Grittiness or Scratchiness
Soreness or Irritation
Burning or Watering
Eye Fatigue

1. C. Report the type of SYMPTOMS you've experienced in the LAST 3 MONTHS:*

Rows	Last 3 Months: Yes	Last 3 Months: No
Dryness, Grittiness or Scratchiness
Soreness or Irritation
Burning or Watering
Eye Fatigue

2. Report the FREQUENCY of your symptoms using the rating list below:*

Rows	0	1	2	3
Dryness, Grittiness or Scratchiness
Soreness or Irritation
Burning or Watering
Eye Fatigue

3. Report the SEVERITY of your symptoms using the rating list below:*

Rows	0	1	2	3	4
Dryness, Grittiness or Scratchiness
Soreness or Irritation
Burning or Watering
Eye Fatigue

0 = No Problems
1 = Tolerable - not perfect, but not uncomfortable
2 = Uncomfortable - irritating, but does not interfere with my day
3 = Bothersome - irritating and interferes with my day
4 = Intolerable - unable to perform my daily tasks
YesNo
If yes, how often?
Should be Empty: