SPEED Questionnaire

If you prefer, you can print a hard copy of this form and fax it to 561-981-8460..

SPEED Questionnaire

Name

Date / Time

Sex

DOB

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:

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

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

0 = No Problem | 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?

Yes

If yes, how often?

	At this visit	Within past 72 hours	Within past 3 months
Dryness, Grittiness or Scratchiness
Soreness or Irritation
Burning or Watering
Eye Fatigue

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

	0 - No Problem	1 - Tolerable	2 - Uncomfortable	3 - Bothersome	4 - Intolerable
Dryness, Grittiness or Scratchiness
Soreness or Irritation
Burning or Watering
Eye Fatigue