Dry Eye 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. 1. Report the type of SYMPTOMS you experience and when they occur:Dryness, Grittiness or Scratchiness* At this time Not at this time Within past 72 hours Not within past 72 hours Within past 3 months Not within past 3 months Soreness or Irritation* At this time Not at this time Within past 72 hours Not within past 72 hours Within past 3 months Not within past 3 months Burning or Watering* At this time Not at this time Within past 72 hours Not within past 72 hours Within past 3 months Not within past 3 months Eye Fatigue* At this time Not at this time Within past 72 hours Not within past 72 hours Within past 3 months Not within past 3 months 2. Report the FREQUENCY of your symptoms using the rating list below: 0 = Never 1 = Sometimes 2 = Often 3 = ConstantDryness, 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 3. 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 tasksDryness, 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 4. Do you use eye drops for lubrication?* Yes No how often? HiddenName* First Last HiddenPhoneHiddenEmail* HiddenNew or returning patient? New Returning Click to see your SPEED score results.
