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
*
Currently
Within past 72 hours
Within past 3 months
None
Soreness or Irritation
*
Currently
Within past 72 hours
Within past 3 months
None
Burning or Watering
*
Currently
Within past 72 hours
Within past 3 months
None
Eye Fatigue
*
Currently
Within past 72 hours
Within past 3 months
None
2. Report the FREQUENCY of your symptoms using the rating list below:
*
Rows
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:
*
Rows
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?
Yes
No
If using drops, how often?
If yes, Which drops do you currently use?
Do you have fluctuating vision? (that is corrected with blinking)
Never
Sometimes
Frequently
A Lot/Always
Have you been told you have blepharitis?
Yes
No
Have you been treated for a stye?
Yes
No
Have you had any of theses symptoms recently?
Eyelid redness
Crusting around lashes
Lid irritation
Name:
*
First Name
Last Name
Date of Birth:
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Email
*
example@example.com
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