Dry Eye Questionnaire
(SPEED) Standardized patient evaluation of eye dryness
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
1. Report the type of symptoms you are experiencing and when they occur:
Symptoms at the visit
*
Yes
No
Dryness, grittiness or scratchiness
Soreness or irritation
Burning or watering
Eye fatigue
Symptoms within 72 hours
*
Yes
No
Dryness, grittiness or scratchiness
Soreness or irritation
Burning or watering
Eye fatigue
Symptoms within past 3 months
*
Yes
No
Dryness, grittiness or scratchiness
Soreness or irritation
Burning or watering
Eye fatigue
2. Report the frequency of your symptoms using the rating list below:
Symptoms
*
0
Never
1
Sometimes
2
Often
3
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:
Symptoms
*
0
No Problems
1
Tolerable
2
Uncomfortable
3
Bothersome
4
Intolerable
Dryness, grittiness or scratchiness
Soreness or irritation
Burning or watering
Eye fatigue
4. Do you use eye drops for lubrication?
Eye drops
*
Yes
No
If yes, how often?
Submit
Should be Empty: