Please use this form for general information purposes only. DO NOT send personal health information through this form. Specific patient care must be addressed during your appointment.Name*Phone*Email* 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. Report the SYMPTOMS you experience and when they occur:Dryness, Grittiness or Scratchiness Yes No Soreness or Irritation Yes No Burning or Watering Yes No Eye Fatigue Yes No 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 Dryness, Grittiness or Scratchiness 0 1 2 3 Report the SEVERITY of your symptoms using the rating list below: (0 = No Problems, 1 = Tolerable, 2 = Uncomfortable, 3 = Bothersome, 4 = Intolerable)Eye Fatigue 0 1 2 3 Soreness or Irritation 0 1 2 3 Burning or Watering 0 1 2 3 Eye Fatigue 0 1 2 3 Do you use eye drops for lubrication? If yes, how often?Please list your symptoms and any other additional commentsCommentsThis field is for validation purposes and should be left unchanged.
