Dry Eye Questionnaire

To get started, click the link below to download the Dry Eye Questionnaire form and simply upload your file using the button provided, or if you prefer, fill out the form below.

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Dry Eye Questionnaire Form

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SPEED™ 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

1. Report the type of SYMPTOMS you experience and when they occur:

Dryness, Grittiness or Scratchiness *

At this timeWithin past 72 hoursWithin past 3 monthsNot at this timeNot within past 72 hoursNot within past 3 months

Soreness or Irritation *

At this timeWithin past 72 hoursWithin past 3 monthsNot at this timeNot within past 72 hoursNot within past 3 months

Burning or Watering *

At this timeWithin past 72 hoursWithin past 3 monthsNot at this timeNot within past 72 hoursNot within past 3 months

Eye Fatigue *

At this timeWithin past 72 hoursWithin past 3 monthsNot at this timeNot within past 72 hoursNot within past 3 months

2. Report the FREQUENCY of your symptoms using the rating list below:

Dryness, Grittiness or Scratchiness *

0 - Never1 - Sometimes2 - Often3 - Constant

Soreness or Irritation *

0 - Never1 - Sometimes2 - Often3 - Constant

Burning or Watering *

0 - Never1 - Sometimes2 - Often3 - Constant

Eye Fatigue *

0 - Never1 - Sometimes2 - Often3 - Constant

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 tasks)

Dryness, Grittiness or Scratchiness *

0 - No Problems1 - Tolerable2 - Uncomfortable3 - Introlerable

Soreness or Irritation *

0 - No Problems1 - Tolerable2 - Uncomfortable3 - Introlerable

Burning or Watering *

0 - No Problems1 - Tolerable2 - Uncomfortable3 - Introlerable

Eye Fatigue *

0 - No Problems1 - Tolerable2 - Uncomfortable3 - Introlerable

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

Please list your symptoms and any other additional comments

Add your name, phone number and email address to see your results:

New or Returning Patient? *