Welcome to the Standardized Patient Evaluation of Eye Dryness (SPEED) Questionnaire!

This short questionnaire allows us to determine the severity and frequency of your eye dryness and will provide a score once completed. Let's get started!

Have you experienced Dryness, Grittiness or Scratchiness within the past 3 months?(Required)

Yes

No

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Have you experienced Dryness, Grittiness or Scratchiness within the past 72 hours?(Required)

Yes

No

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Have you experienced Dryness, Grittiness or Scratchiness today?(Required)

Yes

No

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Have you experienced Soreness or Irritation within the past 3 months?(Required)

Yes

No

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Have you experienced Soreness or Irritation within the past 72 hours?(Required)

Yes

No

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Have you experienced Soreness or Irritation today?(Required)

Yes

No

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Have you experienced Burning or Watering within the past 3 months?(Required)

Yes

No

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Have you experienced Burning or Watering within the past 72 hours?(Required)

Yes

No

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Have you experienced Burning or Watering today?(Required)

Yes

No

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Have you experienced Eye Fatigue within the past 3 months?(Required)

Yes

No

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Have you experienced Eye Fatigue within the past 72 hours?(Required)

Yes

No

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Have you experienced Eye Fatigue today?(Required)

Yes

No

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Now, let's find out how frequently your symptoms are occurring:

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How often do you experience DRYNESS, GRITTINESS, or SCRATCHINESS?(Required)

Never

Sometimes

Often

Constant

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How often do you experience SORENESS or IRRITATION?(Required)

Never

Sometimes

Often

Constant

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How often do you experience BURNING or WATERING?(Required)

Never

Sometimes

Often

Constant

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How often do you experience EYE FATIGUE?(Required)

Never

Sometimes

Often

Constant

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Thanks! Now, help us understand the severity of your symptoms:

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How severe is the DRYNESS, GRITTINESS, or SCRATCHINESS?(Required)

No Problems

Tolerable - not perfect, but not uncomfortable

Uncomfortable - irritating, but does not interfere with my day

Bothersome - irritating and interferes with my day

Intolerable - unable to perform my daily tasks

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How severe is the SORENESS or IRRITATION?(Required)

No Problems

Tolerable - not perfect, but not uncomfortable

Uncomfortable - irritating, but does not interfere with my day

Bothersome - irritating and interferes with my day

Intolerable - unable to perform my daily tasks

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How severe is the BURNING or WATERING?(Required)

No Problems

Tolerable - not perfect, but not uncomfortable

Uncomfortable - irritating, but does not interfere with my day

Bothersome - irritating and interferes with my day

Intolerable - unable to perform my daily tasks

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How severe is the EYE FATIGUE?(Required)

No Problems

Tolerable - not perfect, but not uncomfortable

Uncomfortable - irritating, but does not interfere with my day

Bothersome - irritating and interferes with my day

Intolerable - unable to perform my daily tasks

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Do you use eye drops for lubrication?(Required)

Yes

No

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How often do you use eye drops?(Required)

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One last thing...

please provide us with your information so we can finish calculating your score:

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Name

First Last

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Sex

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Date of Birth

MM slash DD slash YYYY

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This field is hidden when viewing the form

Total Speed Score

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0% Completed!