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 timeWithin past 72 hoursWithin past 3 monthsNot at this timeNot within past 72 hoursNot within past 3 monthsSoreness or Irritation*At this timeWithin past 72 hoursWithin past 3 monthsNot at this timeNot within past 72 hoursNot within past 3 monthsEye Fatigue*At this timeWithin past 72 hoursWithin past 3 monthsNot at this timeNot within past 72 hoursNot within past 3 monthsDouble Vision*At this timeWithin past 72 hoursWithin past 3 monthsNot at this timeNot within past 72 hoursNot within past 3 months2. Report the FREQUENCY of your symptoms using the rating list below:0 = Never 1 = Sometimes 2 = Often 3 = ConstantDryness, Grittiness or Scratchiness0123Soreness or Irritation0123Burning or Watering0123Eye Fatigue*0123Double Vision*01233. 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 tasksDryness, Grittiness or Scratchiness*01234Soreness or Irritation*01234Burning or Watering*01234Eye Fatigue*01234Double Vision*012344. Do you use eye drops for lubrication?*YesNoAdd your name, phone number and email address to see your results:Name* First Last PhoneEmail* New or returning patient?NewReturning
