SPEED™ Questionnaire

Name*

First Last

Date

DOB

Sex:

M
F

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:

Symptoms

Dryness, Grittiness or Scratchiness*

At this visit
Within past 72 hours
Within past 3 months
N/A

Soreness or Irritation*

At this visit
Within past 72 hours
Within past 3 months
N/A

Burning or Watering*

At this visit
Within past 72 hours
Within past 3 months
N/A

Eye Fatigue*

At this visit
Within past 72 hours
Within past 3 months
N/A

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

Symptoms

Dryness, Grittiness or Scratchiness*

Never
Sometimes
Often
Constant

Soreness or Irritation*

Never
Sometimes
Often
Constant

Burning or Watering*

Never
Sometimes
Often
Constant

Eye Fatigue*

Never
Sometimes
Often
Constant

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

Symptoms

Dryness, Grittiness or Scratchiness*

No Problems
Tolerable - not perfect, but not uncomfortable
Uncomfortable - irritating, but does not interfere with my day
Bothersome - irritating and interferes with my day
Intolerable - unable to perform my daily tasks

Soreness or Irritation*

No Problems
Tolerable - not perfect, but not uncomfortable
Uncomfortable - irritating, but does not interfere with my day
Bothersome - irritating and interferes with my day
Intolerable - unable to perform my daily tasks

Burning or Watering*

No Problems
Tolerable - not perfect, but not uncomfortable
Uncomfortable - irritating, but does not interfere with my day
Bothersome - irritating and interferes with my day
Intolerable - unable to perform my daily tasks

Eye Fatigue*

No Problems
Tolerable - not perfect, but not uncomfortable
Uncomfortable - irritating, but does not interfere with my day
Bothersome - irritating and interferes with my day
Intolerable - unable to perform my daily tasks

4. Do you use eye drops for lubrication?*

Yes
No

how often?

SPEED™ Questionnaire

Boas Vision Associates

Boas Vision Associates