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.
Sign in to Google to save your progress. Learn more
Name *
Date of Birth *
MM
/
DD
/
YYYY
Phone number *
Email *
Symptom Frequency
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
 *
Symptom Severity
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
 *
Soreness or Irritation
 *
Burning or Watering
 *
Eye Fatigue
 *
Do you use eye drops for lubrication? *
If you use eye drops for lubrication, how often do you use them?
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Socorro Family Eye Care. Report Abuse
Google Forms