Speed™ Questionnaire

Speed™ Questionnaire

Speed™ Questionnaire

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*



    Eye Fatigue*
    ​​​​​​​

      Double Vision*
      ​​​​​​​

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

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


        Dryness, Grittiness, or Scratchiness
        ​​​​​​​

          Soreness or Irritation​​​​​​​ *
          ​​​​​​​          ​​​​​​​

            Burning or Watering
            ​​​​​​​            ​​​​​​​

              Eye Fatigue*
              ​​​​​​​

                Double Vision*​​​​​​​
                ​​​​​​​

                  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*
                        ​​​​​​​

                          Double Vision*
                          ​​​​​​​

                            4. Do you use eye drops for lubrication?*
                            ​​​​​​​

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


                              Name*​​​​​​​
                              ​​​​​​​

                                New or returning patient?
                                ​​​​​​​

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