SPEED Questionnaire | Center For Sight

Name*

First Last

Email*

1. Report the type of SYMPTOMS you experience and when they occur:

Dryness, Grittiness or Scratchiness

Today

Yes
No

Within past 72 hours

Yes
No

Within past 3 months

Yes
No

Soreness or Irritation

At this visit

Yes
No

Within past 72 hours

Yes
No

Within past 3 months

Yes
No

Burning or Watering

At this visit

Yes
No

Within past 72 hours

Yes
No

Within past 3 months

Yes
No

Eye Fatigue

At this visit

Yes
No

Within past 72 hours

Yes
No

Within past 3 months

Yes
No

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

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

Dryness, Grittiness or Scratchiness

Frequency*

0
1
2
3

Soreness or Irritation

Frequency*

0
1
2
3

Burning or Watering

Frequency*

0
1
2
3

Eye Fatigue

Frequency*

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

Severity*

Soreness or Irritation

Severity*

Burning or Watering

Severity*

Eye Fatigue

Severity*

4. Do you use eye drops for lubrication?

If yes, how often?

Dry Eye Assessment Quiz

Dry Eyes? Take this quiz to find out if you’re a candidate for the revolutionary dry eye treatment, Lipiflow.

1. Report the type of SYMPTOMS you experience and when they occur:

Dryness, Grittiness or Scratchiness

Soreness or Irritation

Burning or Watering

Eye Fatigue

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

Dryness, Grittiness or Scratchiness

Soreness or Irritation

Burning or Watering

Eye Fatigue

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

Dryness, Grittiness or Scratchiness

Soreness or Irritation

Burning or Watering

Eye Fatigue

4. Do you use eye drops for lubrication?