SPEED™ Questionnaire

Section A: Frequency of Symptom

1. Do your eyes feel dry?

2. Do your eyes feel gritty or sandy?

3. Do your eyes burn or sting?

4. Do your eyes feel tired or heavy?

Section B: Severity of Symptoms

5. How severe is the dryness you experience

6. How severe is the grittiness or sandy feeling?

7. How severe is the burning or stinging?

8. How severe is the tiredness or heaviness in your eyes?

Section C: Current Treatments

9. What kind of treatments are you currently using for dry eye?

Your Score: (populated number from answers)

If 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

Contact Information

Please complete the information below and our office will contact you to schedule a dry eye evaluation.

Patient Name:

Phone Number:

Email:

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