Dry Eye Disease 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.

Report the type of SYMPTOMS you experience and when they occur
Dryness, Grittiness or Scratchiness(Required)
Soreness or Irritation(Required)
Burning or Watering(Required)
Eye Fatigue(Required)
0 = Never
1 = Sometimes
2 = Often
3 = Constant
Dryness, Grittiness or Scratchiness(Required)
Soreness or Irritation(Required)
Burning or Watering(Required)
Burning or Watering(Required)
Eye Fatigue(Required)
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
Dryness, Grittiness or Scratchiness(Required)
Soreness or Irritation(Required)
Burning or Watering(Required)
Eye Fatigue(Required)
Do you use eye drops for lubrication?
The SPEED Questionnaire is one tool we use to help assess your dry eye symptoms. No matter what you scored on the quiz, we take your overall eye health very seriously. Please complete the information below and our office will contact you to schedule a dry eye evaluation.
Name(Required)
Address
This field is for validation purposes and should be left unchanged.