Dry Eye Survey
SPEED Questionnaire
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
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.
Report the SYMPTOMS you experience and when they occur:
Dryness, Grittiness or Scratchiness
At This Visit
Yes
No
Within Past 72 Hours
Yes
No
Within Past 3 Months
Yes
No
Soreness or Irritation
At This Visit
Yes
No
Within Past 72 Hours
Yes
No
Within Past 3 Months
Yes
No
Burning or Watering
At This Visit
Yes
No
Within Past 72 Hours
Yes
No
Within Past 3 Months
Yes
No
Eye Fatigue
At This Visit
Yes
No
Within Past 72 Hours
Yes
No
Within Past 3 Months
Yes
No
Report the FREQUENCY of your symptoms using the rating list below:
(0 = Never, 1 = Sometimes, 2 = Often, 3 = Constant)
Dryness, Grittiness, or Scratchiness
0
1
2
3
Soreness or Irritation
0
1
2
3
Burning or Watering
0
1
2
3
Eye Fatigue
0
1
2
3
Report the SEVERITY of your symptoms using the rating list below:
(0 = No Problems, 1 = Tolerable, 2 = Uncomfortable, 3 = Bothersome, 4 = Intolerable)
Dryness, Grittiness or Scratchiness
0
1
2
3
4
Soreness or Irritation
0
1
2
3
4
Burning or Watering
0
1
2
3
4
Eye Fatigue
0
1
2
3
4
Do you use eye drops for lubrication? If yes, how often?
Please list your symptoms and any other additional comments
Submit
Should be Empty: