CDED SPEED Score

CDED SPEED Score
Date

MonthDayYear
Date
Name*

First NameLast Name
Date of Birth

MonthDayYear
Date
Do you currently have any of the following symptoms? Select all that apply.*

DrynessRednessEye FatigueItchingStringy mucous in or around eyesFluctuating visionContact lens discomfortNone
Please rate the FREQUENCY you are experiencing the following symptoms.
Dryness, Grittiness, Scratchiness*

0 Never1 Occasionally2 Sometimes3 Often4 Always
Soreness, Redness*

0 Never1 Occasionally2 Sometimes3 Often4 Always
Eye Fatigue*

0 Never1 Occasionally2 Sometimes3 Often4 Always
Burning and/or watering*

0 Never1 Occasionally2 Sometimes3 Often4 Always
Please rate the SEVERITY of your symptoms.
Dryness, Grittiness, Scratchiness*

0 No issue1 Tolerable2 Uncomfortable3 Bothersome4 Intolerable
Eye pain, soreness, irritation*

0 No issue1 Tolerable2 Uncomfortable3 Bothersome4 Intolerable
Burning and/or watering*

0 No issue1 Tolerable2 Uncomfortable3 Bothersome4 Intolerable
Eye fatigue*

0 No issue1 Tolerable2 Uncomfortable3 Bothersome4 Intolerable
On a scale of 1 to 10, please rate your symptoms

Your photophobia (light sensitivity)*

	1	2	3	4	5	6	7	8	9	10

1 is None, 10 is Severe

Your wind sensitivity*

	1	2	3	4	5	6	7	8	9	10

1 is None, 10 is Severe

Rate the impact of your symptoms on your mood *

	1	2	3	4	5	6	7	8	9	10

1 is None, 10 is Severe

Rate the impact of your symptoms on your daily life*

	1	2	3	4	5	6	7	8	9	10

1 is None, 10 is Severe

Have you experienced the following symptoms during the last week?
Eyes that are sensitive to light*

0 None of the time1 Some of the time2 Half of the time3 Most of the time4 All of the time
Blurred vision*

0 None of the time1 Some of the time2 Half of the time3 Most of the time4 All of the time
Have your eyes limited you from performing any of the following in the last week?
Driving at night*

0 None of the time1 Some of the time2 Half of the time3 Most of the time4 All of the time
Computer Use*

0 None of the time1 Some of the time2 Half of the time3 Most of the time4 All of the time
Have your eyes felt uncomfortable in the following situations in the last week?
Windy conditions*

0 None of the time1 Some of the time2 Half of the time3 Most of the time4 All of the time
Places with low humidity (very dry)*

0 None of the time1 Some of the time2 Half of the time3 Most of the time4 All of the time
Should be Empty: