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
Within past 72 hours
Within past 3 months
Soreness or Irritation *
At this visit
Within past 72 hours
Within past 3 months
Burning or Watering *
At this time
Within past 72 hours
Within past 3 months
Eye Fatigue *
At this time
Within past 72 hours
Within past 3 months

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

  • 0 = Never
  • 1 = Sometimes
  • 2 = Often
  • 3 = Constant
Dryness, Grittiness or Scratchiness
Soreness or Irritation​​​​​​​
Burning or Watering
Eye Fatigue​​​​​​​​​​​​​​
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
Burning or Watering
Soreness or Irritation​​​​​​​
Eye Fatigue
Are you concerned about signs of aging around your eyes or elsewhere on your face? (e.g. fine lines, wrinkles, pigment changes, redness, age spots, etc.)*
Do you have questions about skincare and cosmetics that are safe around the eyes?

Contact Information

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

Would you be interested in receiving information about dry eye treatment, dry eye prevention and more?
New or returning patient?
Do you use eye drops for lubrication?

Find Out Your Score

Click "Find Out My Score" below to receive your SPEED Dry Eye Score via email. (Note: Be sure to check your spam if you are unable to locate email).

Your Score:

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

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Call: (915) 910-5915