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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.
Enter your information below:
(Required.)
First & Last Name
Email
Phone
Date of Submission
Sex (Male / Female)
Date of Birth
2.
Report the type of SYMPTOMS you experience and when they occur:
At this visit
Within past 72 hours
Within past 3 months
Dryness, Grittiness or Scratchiness
-- Select an option --
Yes
No
-- Select an option --
Yes
No
-- Select an option --
Yes
No
Soreness or Irritation
-- Select an option --
Yes
No
-- Select an option --
Yes
No
-- Select an option --
Yes
No
Burning or Watering
-- Select an option --
Yes
No
-- Select an option --
Yes
No
-- Select an option --
Yes
No
Eye Fatigue
-- Select an option --
Yes
No
-- Select an option --
Yes
No
-- Select an option --
Yes
No
3.
Report the FREQUENCY of your symptoms using the rating list below:
0 = Never
1 = Sometimes
2 = Often
3 = Constant
0
1
2
3
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
4.
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
0
1
2
3
4
Dryness, Grittiness or Scratchiness
0
1
2
3
4
Soreness or Irritation
0
1
2
3
4
Burning or Watering
0
1
2
3
4
Eye Fatigue
0
1
2
3
4
5.
Do you use eye drops for lubrication?
Yes
No
If yes, how often?