Speed Questionnarie

Standardized Patient Evaluation of Eye Dryness (SPEED) Questionnaire

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:
Dryness, Grittiness or Scratchiness*

CurrentlyWithin past 72 hoursWithin past 3 monthsNone
Soreness or Irritation*

CurrentlyWithin past 72 hoursWithin past 3 monthsNone
Burning or Watering*

CurrentlyWithin past 72 hoursWithin past 3 monthsNone
Eye Fatigue*

CurrentlyWithin past 72 hoursWithin past 3 monthsNone

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

	NEVER	SOMETIMES	OFTEN	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:*

	NO PROBLEMS	TOLERABLE	UNCOMFORTABLE	BOTHERSOME	INTOLERABLE
Dryness, Grittiness or Scratchiness
Soreness or Irritation
Burning or Watering
Eye Fatigue

4. Do you use eye drops for lubrication?

YesNo
If using drops, how often?
If yes, Which drops do you currently use?
Do you have fluctuating vision? (that is corrected with blinking)

NeverSometimesFrequentlyA Lot/Always
Have you been told you have blepharitis?

YesNo
Have you been treated for a stye?

YesNo
Have you had any of theses symptoms recently?

Eyelid rednessCrusting around lashesLid irritation
Name:*

First NameLast Name
Date of Birth:*

MonthDayYear
Date
Email*
example@example.com
Should be Empty:

Standardized Patient Evaluation of Eye Dryness (SPEED) Questionnaire