Dry Eye Disease is a common reason for patients to visit eye doctors. Please take a moment to thoughtfully complete this questionnaire.
Report the SYMPTOMS you experience and when they occur:
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
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
Do you use eye drops for lubrication? If yes, how often?
Please list your symptoms and any other additional comments
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 symptoms5-7 you are experiencing MODERATE dry eye symptoms8+ you are experiencing SEVERE dry eye symptomsThe 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?
Please use the form below to request an appointment. Our team will connect with you shortly to confirm your appointment. Thank you!
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