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Dry Eye Questionnaire

SPEED Questionnaire

For the Standardized Patient Evaluation of Eye Dryness (SPEED) Questionnaire, please answer the following quesitons by checking the box that best represents your answer. Select only one answer per question. 

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1. Please report the type of SYMPTOMS you experience and WHEN they occur: 

Dryness, Grittiness or Scratchiness:
Soreness or Irritation:
Burning or Watering:
Eye Fatigue:

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:

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

0=No Problems 1=Tolerable 2=Uncomfortable 3=Bothersome 4=Intolerable

Dryness, Grittiness or Scratchiness:
Soreness or Irritation:
Burning or Watering:
Eye Fatigue:
Do you use lubricating eye drops?

Thanks for submitting! The Doctor will review your response and contact you shortly!

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