SPEED Dry Eye Questionnaire
Date
*
Date
*
-
Month
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Day
Year
Date
Name
*
First Name
Last Name
Birth Date
*
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Month
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Day
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1927
1926
1925
1924
1923
1922
1921
1920
Year
Phone Number
*
Please enter a valid phone number.
Gender
Male
Female
N/A
How FREQUENTLY do you experience the following dry eye symptoms?
Dryness, Grittiness, Scratchiness:
Never
Sometimes
Often
Constant
Soreness or Irritation:
Never
Sometimes
Often
Constant
Burning or Watering:
Never
Sometimes
Often
Constant
Eye Fatigue:
Never
Sometimes
Often
Constant
Calculation
How SEVERE are your dry eye symptoms?
Dryness, Grittiness or Scratchiness:
No Problems
Tolerable - not perfect but not uncomfortable
Uncomfortable - irritating but does not interfere with my day
Bothersome - irritating and interferes with my day
Intolerable - unable to perform my daily tasks
Soreness or Irritation:
No Problems
Tolerable - not perfect but not uncomfortable
Uncomfortable - irritating but does not interfere with my day
Bothersome - irritating and interferes with my day
Intolerable - unable to perform my daily tasks
Burning or Watering:
No Problems
Tolerable - not perfect but not uncomfortable
Uncomfortable - irritating but does not interfere with my day
Bothersome - irritating and interferes with my day
Intolerable - unable to perform my daily tasks
Eye Fatigue:
No Problems
Tolerable - not perfect but not uncomfortable
Uncomfortable - irritating but does not interfere with my day
Bothersome - irritating and interferes with my day
Intolerable - unable to perform my daily tasks
Calculation
When have you experienced these symptoms?
Today
Within the past 72 hours
Within the past 3 months
Please select Yes or No to the following questions
Yes
No
Not
Applicable
Do you have difficulty reading?
Do you have difficulty using a computer?
Do you have difficulty driving?
Do you have difficulty watching television?
Do you have difficulty wearing contact lenses?
Do you have difficulty being outdoors?
Do your symptoms worsen throughout the day?
Do you use drops and/or ointment?
Yes
No
If yes, which drops and/or ointment?
How frequently?
Do you experience blurred or fluctuating vision?
Yes
No
Do you wear contact lenses?
Yes
No
If yes, how long can you wear comfortably?
For office use only:
Total SPEED score (Frequency + Severity) = ______ /28
Submit
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