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

Burning or Watering

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

Your Score:

Do you use eye drops for lubrication? If yes, how often?

Please list your symptoms and any other additional comments