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*0123Soreness or Irritation*0123Burning or Watering*0123Eye Fatigue*01233. 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*01234Soreness or Irritation*01234Burning or Watering*01234Eye Fatigue*012344. Do you use eye drops for lubrication?*YesNoIf yes, how often? Total SPEED scoreFrequency + SeverityWant 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*
