SPEED Questionnaire


SPEED Questionnaire


Sex


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.

Report the SYMPTOMS you experience and when they occur:

Dryness, Grittiness, or Scratchiness

Soreness or Irratation

Burning or Watering
Eye Fatigue
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
Do you use eye drops for lubrication? If yes, how often?
Please list your symptoms and any other additional comments