SPEED™ Questionnaire 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. 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 = ConstantDryness, 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 tasksDryness, 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 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 PhoneEmail* New or returning patient? New Returning Thank you for completing the SPEED Questionnaire! This assessment is your first step toward finding relief from dry eye.Total SPEED scoreFrequency + SeverityIf your score is: 0-4 you are experiencing MILD dry eye symptoms 5-7 you are experiencing MODERATE dry eye symptoms 8+ you are experiencing SEVERE dry eye symptoms The SPEED Questionnaire is one tool we use to help assess your dry eye symptoms. No matter what you scored on the quiz, we take your overall eye health very seriously. Please complete the information below and our office will contact you to schedule a dry eye evaluation.Would you like our practice to contact you to schedule a dry eye evaluation? Yes No Would you be interested in receiving information about dry eye treatment, dry eye prevention and more? Yes No Thank you taking our Speed™ Questionnaire! While this isn't a true assessment regarding whether you have dry eye syndrome or not, many practices use questions like these to indicate patients most at risk for dry eye. This quiz is not designed to constitute advice as to your visual health or, more particularly, to provide a diagnosis. An accurate diagnosis for vision problems and conditions can only be made by an eye practitioner following a complete eye examination. For more information about your dry eye concerns, speak to your eye doctor at your next eye exam or you can schedule a dry eye appointment by calling us at 954-320-0048. Make sure to ask our team about receiving coverage through your medical and/or vision insurance.