SPEED QUESTIONNAIRE

SPEED QUESTIONNAIRE
Name*

First NameMiddle NameLast Name
Date

MonthDayYear
Date
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:
Are you experiencing Dryness, Grittiness or Scratchiness today?*

YesNo
Did you experience Dryness, Grittiness or Scratchiness within the past 72 hours?*

YesNo
Did you experience Dryness, Grittiness or Scratchiness within the past 3 months?*

YesNo
Are you experiencing Soreness or Irritation today?*

YesNo
Did you experience Soreness or Irritation within the past 72 hours?*

YesNo
Did you experience Soreness or Irritation within the past 3 months?*

YesNo
Are you experience Burning or Watering today?*

YesNo
Did you experience Burning or Watering within the past 72 hours?*

YesNo
Did you experience Burning or Watering within the past 3 months?*

YesNo
Are you experiencing eye fatigue today?*

YesNo
Did you experiencing eye fatigue in the past 72 hours?*

YesNo
Did you experiencing eye fatigue in the past 3 months?*

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

Symptoms*

	0	1	2	3
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	1	2	3	4
Dryness, Grittiness or Scratchiness
Soreness or Irritation
Burning or Watering
Eye Fatigue

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
4. Do you use eye drops for lubrication?*

YesNo
How often?

COVID-19 Pandemic Eye Exam and Treatment Consent
Please read the following statements and initial next to the following statements to indicate your agreement. If you cannot positively affirm to all of these questions, you will be asked to postpone or reschedule your visit to a later date.
I do not currently, nor have I had in the last two (2) weeks, a fever, cough, sore throat, loss ofsmell/taste or other cold symptoms.
To the best of my knowledge, I do not have,nor have I been in direct contact with someonewho has confirmed diagnosis of COVID-19 or a presumptive positive COVID-19 test result in the lastthirty (30) days.
Neither I, nor anyone living in my immediate household, have travelled outside of the UnitedStates in the last 30 days.
If the answers to any of these questions change from now until my appointment time, I understand I need to inform Pinnacle Optometric Eye Care of any changes as soon as possible. I also understand my appointment will need to be postponed.
I have read the above and have answered the health questions - above honestly and to the best of myknowledge. I understand that Pinnacle Optometric Eye Care, its doctors and team members are takingprecautions to limit any potential exposure I may have to the COVID-19 virus. I also understand thatthere is no definitive way to eliminate potential exposure by one hundred percent.
By signing this form below, I agree that I will not hold Pinnacle Optometric Eye Care or any of its doctors or team members personally responsible should I, or someone I come in contact with, become positive or presumptively positive diagnosed with the COYID-19 virus. There are certain inherent risks associated with an eye exam during a pandemic and I assume full responsibility for personal illness that may result and further release and discharge Pinnacle Optometric Eye Care and its doctors and team members for injury, loss or damage arising out of my visit. I understand that COVID-19 infection can
lead to illness, disability or even death and knowingly take the risk of exposure as I deem my eye exam to be essential to the maintenance of my vision.
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SPEED QUESTIONNAIRE

COVID-19 Pandemic Eye Exam and Treatment Consent