SPEED Dry Eye Questionnaire

SPEED Dry Eye Questionnaire
Date*
Date*

MonthDayYear
Date
Name*

First NameLast Name
Birth Date*

MonthDayYear
Phone Number*
Please enter a valid phone number.
Gender

MaleFemaleN/A
How FREQUENTLY do you experience the following dry eye symptoms?
Dryness, Grittiness, Scratchiness:

NeverSometimesOftenConstant
Soreness or Irritation:

NeverSometimesOftenConstant
Burning or Watering:

NeverSometimesOftenConstant
Eye Fatigue:

NeverSometimesOftenConstant
Calculation
How SEVERE are your dry eye symptoms?
Dryness, Grittiness or Scratchiness:

No ProblemsTolerable - not perfect but not uncomfortableUncomfortable - irritating but does not interfere with my dayBothersome - irritating and interferes with my dayIntolerable - unable to perform my daily tasks
Soreness or Irritation:

No ProblemsTolerable - not perfect but not uncomfortableUncomfortable - irritating but does not interfere with my dayBothersome - irritating and interferes with my dayIntolerable - unable to perform my daily tasks
Burning or Watering:

No ProblemsTolerable - not perfect but not uncomfortableUncomfortable - irritating but does not interfere with my dayBothersome - irritating and interferes with my dayIntolerable - unable to perform my daily tasks
Eye Fatigue:

No ProblemsTolerable - not perfect but not uncomfortableUncomfortable - irritating but does not interfere with my dayBothersome - irritating and interferes with my dayIntolerable - unable to perform my daily tasks
Calculation
When have you experienced these symptoms?

TodayWithin the past 72 hoursWithin 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?

YesNo
If yes, which drops and/or ointment?
How frequently?
Do you experience blurred or fluctuating vision?

YesNo
Do you wear contact lenses?

YesNo
If yes, how long can you wear comfortably?
For office use only:
Total SPEED score (Frequency + Severity) = ______ /28
Should be Empty:

SPEED Dry Eye Questionnaire

How FREQUENTLY do you experience the following dry eye symptoms?

How SEVERE are your dry eye symptoms?