Wood Eyecare Centers
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Home
Locations
Why Choose Us
Doctors
Patients
Patient Forms
Patient Portal
Eyeglass Guide
Education
Optos
Eye Care Articles
Effects of Blue Light on Eyes
Contact Lens Homework
Virtual Try-on
Our Practice
Reviews
Our Services
Insurance Accepted
Cancellation Policy
Online Ordering
Contacts
EyePromise
Meet AquaDoc and OptiLight
Cosmetic Corner
Giving Back
Wood Eye Care News!
3 Locations
Lilburn: 770-978-2990
Lawrenceville: 770-237-8820
Monroe: 770-267-2573
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 visit
Within past 72 hours
Within past 3 months
None
Soreness or Irritation
*
At this visit
Within past 72 hours
Within past 3 months
None
Burning or Watering
*
At this visit
Within past 72 hours
Within past 3 months
None
Eye Fatigue
*
At this visit
Within past 72 hours
Within past 3 months
None
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?
*
Yes
No
If using drops, how often?
Name:
*
First Name
Last Name
Date of Birth:
*
-
Month
-
Day
Year
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).
FIND OUT MY SCORE
Should be Empty:
Home
Locations
Why Choose Us
Doctors
Patients
Patient Forms
Patient Portal
Eyeglass Guide
Education
Optos
Eye Care Articles
Effects of Blue Light on Eyes
Contact Lens Homework
Virtual Try-on
Our Practice
Reviews
Our Services
Insurance Accepted
Cancellation Policy
Online Ordering
Contacts
EyePromise
Meet AquaDoc and OptiLight
Cosmetic Corner
Giving Back
Wood Eye Care News!