SPEED Dry Eye Questionnaire - Eyecare Virginia Beach

Dry Eye Questionnaire

Dry Eye Disease is the most frequent reason patients visit an eye doctor. This questionnaire is a helpful first step in measuring the frequency & severity of dry eye symptoms. Since dry eye is the most frequent complaint, we ask that you take a few moments and thoughtfully complete the questionnaire below.

Name*

First Last

Email*

How FREQUENT do your eyes feel Dryness, Grittiness or Scratchiness?*

“0” for NEVER, “1” for SOMETIMES, “2” for OFTEN or “3” for CONSTANT

Please enter a number from 0 to 3.

How FREQUENT do your eyes feel Soreness or Irritation?*

“0” for NEVER, “1” for SOMETIMES, “2” for OFTEN or “3” for CONSTANT

Please enter a number from 0 to 3.

How FREQUENT do your eyes feel Burning or Watering?*

“0” for NEVER, “1” for SOMETIMES, “2” for OFTEN or “3” for CONSTANT

Please enter a number from 0 to 3.

How FREQUENT do your eyes feel Eye Fatigue?*

“0” for NEVER, “1” for SOMETIMES, “2” for OFTEN or “3” for CONSTANT

Please enter a number from 0 to 3.

Enter the SEVERITY of your eyes Dryness, Grittiness or Scratchiness?*

“0” for NO PROBLEMS

“1” for Tolerable (Not perfect but not uncomfortable)

“2” for UNCOMFORTABLE (irritating but does not interfere with my day)

“3” for BOTHERSOME (irritating and interferes with my day)

“4” for INTOLERABLE (unable to perform my daily tasks)

Please enter a number from 0 to 4.

Enter the SEVERITY of your eyes Soreness or Irritation?*

“0” for NO PROBLEMS

“1” for Tolerable (Not perfect but not uncomfortable)

“2” for UNCOMFORTABLE (irritating but does not interfere with my day)

“3” for BOTHERSOME (irritating and interferes with my day)

“4” for INTOLERABLE (unable to perform my daily tasks)

Please enter a number from 0 to 4.

Enter the SEVERITY of your eyes Burning or Watering?*

“0” for NO PROBLEMS

“1” for Tolerable (Not perfect but not uncomfortable)

“2” for UNCOMFORTABLE (irritating but does not interfere with my day)

“3” for BOTHERSOME (irritating and interferes with my day)

“4” for INTOLERABLE (unable to perform my daily tasks)

Please enter a number from 0 to 4.

Enter the SEVERITY of your eyes Eye Fatigue?*

“0” for NO PROBLEMS

“1” for Tolerable (Not perfect but not uncomfortable)

“2” for UNCOMFORTABLE (irritating but does not interfere with my day)

“3” for BOTHERSOME (irritating and interferes with my day)

“4” for INTOLERABLE (unable to perform my daily tasks)

Please enter a number from 0 to 4.

Your Total SPEED SCORE is:

I have experienced symptoms:

Today

Within the past 72 hours

Within the past 3 months

Do you use eye drops and/or ointments?

Yes

Have you been told you have blepharitis?

Yes

Have you been treated for a stye?

Yes

Do you have fluctuating vision?

That seems to clear up when you blink

Never

Sometimes

Frequently

A Lot / Always

Do you use a CPAP Machine?

Yes

Phone

This field is for validation purposes and should be left unchanged.

Dry Eye Questionnaire

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Office Hours

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