Dryeyetest

Standardized Patient Evaluation of Eye Dryness (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.
1. Report the type of SYMPTOMS you experience and when they occur:
Dryness, Grittiness or Scratchiness*

At this visitWithin past 72 hoursWithin past 3 monthsNone
Soreness or Irritation*

At this visitWithin past 72 hoursWithin past 3 monthsNone
Burning or Watering*

At this visitWithin past 72 hoursWithin past 3 monthsNone
Eye Fatigue*

At this visitWithin past 72 hoursWithin past 3 monthsNone

2. Report the FREQUENCY of your symptoms using the rating list below:*

	NEVER	SOMETIMES	OFTEN	CONSTANT
Dryness, Grittiness or Scratchiness
Soreness or Irritation
Burning or Watering
Eye Fatigue

3. Report the SEVERITY of your symptoms using the rating list below:*

	NO PROBLEMS	TOLERABLE	UNCOMFORTABLE	BOTHERSOME	INTOLERABLE
Dryness, Grittiness or Scratchiness
Soreness or Irritation
Burning or Watering
Eye Fatigue

4. Do you use eye drops for lubrication?*

YesNo
If using drops, how often?
Name:*

First NameLast Name
Date of Birth:*

MonthDayYear
Date
Email*
example@example.com
Total SPEED Score
Find Out Your Score!

Click "Find Out My Score" below to receive your SPEED Dry Eye Score via email. (Note: Be sure to check your spam if you are unable to locate email).
Should be Empty:

Lilburn Office
3050 Five Forks Trickum Rd
Suite 112
Lilburn, GA 30047
770-978-2990 Call or text!

Lawrenceville Office
2100 Riverside Parkway
Suite 108
Lawrenceville, GA 30043
770-237-8820 Call or text!

Monroe Office
428 W Highland Ave Monroe, GA 30655
770-267-2573
Call or text!

Standardized Patient Evaluation of Eye Dryness (SPEED) Questionnaire