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Dry Eye SPEED Questionnaire

Name: Family Vision Center
Address: 228 South Courtenay Parkway, Merritt Island, FL, 32952, US
Telephone: 321-454-3002
Price range: $000 - $300

Name:
First Last
Date:
MM slash DD slash YYYY
Date of Birth:
MM slash DD slash YYYY
Sex:
- Male
- Female
Dry Eye Disease is the most frequent reason that patients visit eye doctors. We are concerned that you may be suffering with this condition as well. Therefore, we ask that you take a few moments and thoughtfully complete the questionnaire below.
Report the FREQUENCY of dry eye symptoms you are experiencing by checking Never, Sometimes, Often or Constant using the numbering system below:
0 = Never
1 = Sometimes
2 = Often
3 = Constant
0 1 2 3
Dryness, Grittiness or Scratchiness
Soreness or Irritation
Burning or Watering
Eye Fatigue
Report the SEVERITY of your symptoms using the ratings 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
0 1 2 3 4
Dryness, Grittiness or Scratchiness
Soreness or Irritation
Burning or Watering
Eye Fatigue
Please check if you have experienced symptoms:
- Today
- Within the last past 72 hours
- Within past 3 months
Do you use eye drops and/or ointment?
- Yes
- No
If yes, which drops do you use?
Have you been told that you have blepharitis?
- Yes
- No
Have you been treated for a stye?
- Yes
- No
Do you have fluctuating vision problems?
(That can be corrected with blinking)
- Never
- Sometimes
- Frequently
- A Lot/Always

	0	1	2	3
Dryness, Grittiness or Scratchiness
Soreness or Irritation
Burning or Watering
Eye Fatigue

	0	1	2	3	4
Dryness, Grittiness or Scratchiness
Soreness or Irritation
Burning or Watering
Eye Fatigue

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