SPEED™ Questionnaire Take the Dry Eye Quiz and view your score immediately! 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. 1. Report the type of SYMPTOMS you experience and when they occur:Dryness, Grittiness or Scratchiness* At this time Not at this time Within past 72 hours Not within past 72 hours Within past 3 months Not within past 3 months Soreness or Irritation* At this time Not at this time Within past 72 hours Not within past 72 hours Within past 3 months Not within past 3 months Burning or Watering* At this time Not at this time Within past 72 hours Not within past 72 hours Within past 3 months Not within past 3 months Eye Fatigue* At this time Not at this time Within past 72 hours Not within past 72 hours Within past 3 months Not within past 3 months 2. Report the FREQUENCY of your symptoms using the rating list below: 0 = Never 1 = Sometimes 2 = Often 3 = ConstantDryness, Grittiness or Scratchiness* 0 1 2 3 Soreness or Irritation* 0 1 2 3 Burning or Watering* 0 1 2 3 Eye Fatigue* 0 1 2 3 3. Report the SEVERITY of your symptoms using the rating list below: 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 tasksDryness, Grittiness or Scratchiness* 0 1 2 3 4 Soreness or Irritation* 0 1 2 3 4 Burning or Watering* 0 1 2 3 4 Eye Fatigue* 0 1 2 3 4 4. Do you use eye drops for lubrication?* Yes No If yes, how often? Thank you for completing the SPEED Questionnaire! This assessment is your first step toward finding relief from dry eye.Total SPEED scoreFrequency + SeverityIf 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.Want to learn more about your score and dry eye treatments? Yes No Thank you for filling out this survey. Please fill out your information below and we will contact you shortly” Name* First Last Phone*Email* Would you like our practice to contact you to schedule a dry eye evaluation? Yes No Would you be interested in receiving information about dry eye treatment, dry eye prevention and more? Yes No
