SPEED Questionnaire

Standard Patient Evaluation of Eye Dryness

Patient Information

First Name *

Last Name *

Email Address *

Date of Birth *

Sex *

Check all that apply for each timeframe.

Symptom	Today	Past 72 Hours	Past 3 Months
Dryness, Grittiness, or Scratchiness
Soreness or Irritation
Burning or Watering
Eye Fatigue

Do you use eye drops for lubrication?

How often?

This questionnaire is for informational purposes only and does not constitute a medical diagnosis.

Please consult with an eye care professional for proper evaluation and treatment.