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*

Soreness or Irritation*

Burning or Watering*

Eye Fatigue*

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

0 = Never
1 = Sometimes
2 = Often
3 = Constant

Dryness, 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 tasks

Dryness, Grittiness or Scratchiness*

Soreness or Irritation*

Burning or Watering*

Eye Fatigue*

4. Do you use eye drops for lubrication?*

Yes
No

how often?

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

Name*

First Last

Phone

Email*

New or returning patient?

New
Returning

Click to see your SPEED score results.

Speed II Questionnaire

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Citrus Heights

Gold River

Rocklin

Folsom

Midtown

Ask Here, Voice Search

Citrus Heights

Gold River

Rocklin

Folsom

Midtown

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