SPEED Questionnaire

Sex

MaleFemale

Dry Eye Disease is a common reason for patients to visit eye doctors. Please take a moment to thoughtfully complete this questionnaire.

Report the SYMPTOMS you experience and when they occur:

Symptoms	Today	Within Past 72 Hours	Within Past 3 Months
Dryness, Grittiness or Scratchiness	Yes No	Yes No	Yes No
Soreness or Irritation	Yes No	Yes No	Yes No
Burning or Watering	Yes No	Yes No	Yes No
Eye Fatigue	Yes No	Yes No	Yes No

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

Dryness, Grittiness, or Scratchiness

0123

Soreness or Irritation

0123

Burning or Watering

0123

Eye Fatigue

0123

Report the SEVERITY of your symptoms using the rating list below:
(0 = No Problems, 1 = Tolerable, 2 = Uncomfortable, 3 = Bothersome, 4 = Intolerable)

Do you use eye drops for lubrication? If yes, how often?

Please list your symptoms and any other additional comments

Thank you for completing the SPEED Questionnaire!
This assessment is your first step toward finding relief from dry eye.

Your Score:

If your score is:
0-4 you are experiencing MILD dry eye symptoms
5-7 you are experiencing MODERATE dry eye symptoms
8+ you are experiencing SEVERE dry eye symptoms

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.

Would you like our practice to contact you to schedule a dry eye evaluation?

YesNo

Would you be interested in receiving information about dry eye treatment, dry eye prevention and more?

YesNo

SPEED Questionnaire

SPEED Questionnaire

SPEED Questionnaire

SPEED Questionnaire

SPEED Questionnaire

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