Speed Questionnaire

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*

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*

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*

Eye Fatigue*

4. Do you use eye drops for lubrication?*

If yes, How often?

Add your name, phone number and email address to see your results:

Name*

Phone

Email*

New or returning patient?

Click to see your SPEED score results.

SPEED™ Questionnaire Results

Thank you for completing the SPEED Questionnaire!
This assessment is your first step toward finding relief from dry eye.

Your Score:

0

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


The SPEED Questionnaire is one tool we use to help assess your dry eye symptoms. No matter what you scored on the quiz, we take your overall eye health very seriously. Please complete the information below and our office will contact you to schedule a dry eye evaluation.

Would you like our practice to contact you to schedule a dry eye evaluation?

Would you be interested in receiving information about dry eye treatment, dry eye prevention and more?

Thank you taking our Speed™ Questionnaire! While this isn't a true assessment regarding whether you have dry eye syndrome or not, many practices use questions like these to indicate patients most at risk for dry eye.

This quiz is not designed to constitute advice as to your visual health or, more particularly, to provide a diagnosis. An accurate diagnosis for vision problems and conditions can only be made by an eye practitioner following a complete eye examination.

For more information about your dry eye concerns, speak to your eye doctor at your next eye exam or you can schedule a dry eye appointment by calling us at 704-271-5544. Make sure to ask our team about receiving coverage through your medical and/or vision insurance.

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