SPEED Questionnaire

Name*

First and Last Name

Date of Birth*

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 question.

1. Report the type of SYMPTOMS you experience and when they occur:

	Currently	Within past 72 hours	Within Past 3 months	N/A
Dryness, Grittiness, or Scratchiness
Soreness or Irritation
Burning or Watering
Eye Fatigue

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

	0 - Never	1 - Sometimes	2 - Often	3 - Constant
Dryness, Grittiness, or Scratchiness
Soreness or Irritation
Burning or Watering
Eye Fatigue

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

	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

4. Do you use eye drops for lubrication?

YesNo

If yes, how often?