Dry Eye Survey

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.

Report the SYMPTOMS you experience and when they occur:

Symptoms	At This Visit	Within Past 72 Hours	Within Past 3 Months
Dryness, Grittiness or Scratchiness	Yes No	Yes No	Yes No
Soreness or Irritation	Yes No	Yes No	Yes No
Burning or Watering	Yes No	Yes No	Yes No
Eye Fatigue	Yes No	Yes No	Yes No

Report the FREQUENCY of your symptoms using the rating list below:
(0 = Never, 1 = Sometimes, 2 = Often, 3 = Constant)

Please list your symptoms and any other additional comments

Dry Eye Survey

SPEED Questionnaire

Contact Information

Hours of Operation

Dry Eye Survey

SPEED Questionnaire

Contact Information

Hours of Operation

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