SPEED Dry Eye Questionnaire

Patient Name:

Date:

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 ScratchinessAt this visit - YESAt this visit - NOWithin the past 72 hours - YESWithin the past 72 hours - NOWithin the past 3 months - YESWithin the past 3 months - NO

Report the FREQUENCY of your symptoms using the rating list

0 = Never

1 = Sometimes

2 = Often

3 = Constant

Dryness, Grittiness or Scratchiness0123

Soreness or Irritation0123

Burning or Watering0123

Eye Fatigue0123

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 tasks

Do you use eye drops for lubrication?YesNo

If yes, how often?

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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:

Report the FREQUENCY of your symptoms using the rating list

Report the SEVERITY of your symptoms using the rating list below: