Dry Eye SPEED Questionnaire 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 = Constant0123Dryness, Grittiness or ScratchinessSoreness or IrritationBurning or WateringEye FatigueReport 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 tasks01234Dryness, Grittiness or ScratchinessSoreness or IrritationBurning or WateringEye FatiguePlease 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