Dry Eye SPEED Questionnaire in Santa Monica

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 timeWithin past 72 hoursWithin past 3 monthsNot at this timeNot within past 72 hoursNot within past 3 months

Soreness or Irritation*

At this timeWithin past 72 hoursWithin past 3 monthsNot at this timeNot within past 72 hoursNot within past 3 months

Burning or Watering*

At this timeWithin past 72 hoursWithin past 3 monthsNot at this timeNot within past 72 hoursNot within past 3 months

Eye Fatigue*

At this timeWithin past 72 hoursWithin past 3 monthsNot at this timeNot within past 72 hoursNot within past 3 months

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

0 = Never
1 = Sometimes
2 = Often
3 = Constant

Dryness, Grittiness or Scratchiness*

NeverSometimesOftenConstant

Soreness or Irritation*

NeverSometimesOftenConstant

Burning or Watering*

NeverSometimesOftenConstant

Eye Fatigue*

NeverSometimesOftenConstant

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*

No ProblemsTolerable - not perfect, but not uncomfortableUncomfortable - irritating, but does not interfere with my dayBothersome - irritating and interferes with my dayIntolerable - unable to perform my daily tasks

Burning or Watering*

Soreness or Irritation*

Eye Fatigue*

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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?

YesNo

New or returning patient?

NewReturning

Do you use eye drops for lubrication?

YesNo

If yes, How often?

Click to see your SPEED score results.

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SPEED™ Questionnaire Results

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

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

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.

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Thank you for 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.

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 (424) 402-5700.

Thank you for submitting your questionnaire, we will calculate your score and follow-up with you shortly.

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