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 time
Not at this time
Within past 72 hours
Not within past 72 hours
Within past 3 months
Not within past 3 months

Soreness or Irritation*

At this time
Not at this time
Within past 72 hours
Not within past 72 hours
Within past 3 months
Not within past 3 months

Burning or Watering*

At this time
Not at this time
Within past 72 hours
Not within past 72 hours
Within past 3 months
Not within past 3 months

Eye Fatigue*

At this time
Not at this time
Within past 72 hours
Not within past 72 hours
Within past 3 months
Not within past 3 months

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

0 = Never
1 = Sometimes
2 = Often
3 = Constant

Dryness, Grittiness or Scratchiness*

0
1
2
3

Soreness or Irritation*

0
1
2
3

Burning or Watering*

0
1
2
3

Eye Fatigue*

0
1
2
3

3. 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*

Eye Fatigue*

4. Do you use eye drops for lubrication?*

Yes
No

how often?

Add your name, phone number and email address to see your results:

Name*

First Last

Phone

Email*

New or returning patient?

New
Returning

Click to see your SPEED score results.

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Children Vision Assessment Score

SPEED™ Questionnaire

Clarity Optometry