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Speed Questionnaire

Do you think you have Dry Eye? Take our questionnaire below and submit it to find out!

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.

Report the type of SYMPTOMS you experience and when they occur:

Dryness, Grittiness or Scratchiness*

At this timeNot at this timeWithin past 72 hoursNot within past 72 hoursWithin past 3 monthsNot within past 3 months

Soreness or Irritation*

At this timeNot at this timeWithin past 72 hoursNot within past 72 hoursWithin past 3 monthsNot within past 3 months

Burning or Watering*

At this timeNot at this timeWithin past 72 hoursNot within past 72 hoursWithin past 3 monthsNot within past 3 months

Eye Fatigue*

At this timeNot at this timeWithin past 72 hoursNot within past 72 hoursWithin past 3 monthsNot within past 3 months

Report the FREQUENCY of your symptoms using the rating list below:
0 = Never
1 = Sometimes
2 = Often
3 = Constant

Dryness, Grittiness or Scratchiness*

0123

Soreness or Irritation*

0123

Burning or Watering*

0123

Eye Fatigue*

0123

Report the SEVERITY of your symptoms using the rating list below
0 = No Problems
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

Dryness, Grittiness or Scratchiness*

0123

Soreness or Irritation*

0123

Burning or Watering*

0123

Eye Fatigue*

0123

Do you use eye drops for lubrication?*

YesNo

If yes, how often?

Add your name, phone number and email address to see your results

New or returning patient?

YesNo

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Download SPEED Questionnaire

If you do not already have AdobeReader® installed on your computer, Click Here to download it now.
Download the necessary form(s), print it out and fill in the required information.
Fax or email us your completed form(s) or bring it with you to your appointment.