SPEED Questionnaire

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

At this visitWithin past 72 hoursWithin past 3 months
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 - Never1 - Sometimes2 - Often3 - 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 = 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

0 - No Problem1 - Tolerable2 - Uncomfortable3 - Bothersome4 - Intolerable
Dryness, Grittiness or Scratchiness
Soreness or Irritation
Burning or Watering
Eye Fatigue