SPEED™ Questionnaire Dry Eye Questionnaire Name* First Last HiddenDate* MM slash DD slash YYYY Dry Eye Disease is the most frequent reason the patients visit eye doctors. We are concerned that you may be suffering with this condition as well. Therefore, we ask that you take a few moments and thoughtfully complete the questions below.Report the FREQUENCY of the dry eye symptoms. How many times are you experiencing the symptoms?Dryness, Gritiness or Scratchiness 0 - Never 1 - Sometimes 2 - Often 3 - Constant Soreness or Irritation 0 - Never 1 - Sometimes 2 - Often 3 - Constant Burning or Watering 0 - Never 1 - Sometimes 2 - Often 3 - Constant Eye Fatigue 0 - Never 1 - Sometimes 2 - Often 3 - Constant HiddenResult - FREQUENCY of the dry eye symptomsReport the SEVERITY of the dry eye symptoms Never = No problems Tolerable = Not perfect, but not uncomfortable Uncomfortable = Irritating but does not interfere with my day Bothersome = Irritating and interferes with my day Intolerable = Unable to perform my daily tasksDryness, Gritiness or Scratchiness 0 - Never 1 - Tolerable 2 - Uncomfortable 3 - Bothersome 4 - Intolerable Soreness or Irritation 0 - Never 1 - Tolerable 2 - Uncomfortable 3 - Bothersome 4 - Intolerable Burning or Watering 0 - Never 1 - Tolerable 2 - Uncomfortable 3 - Bothersome 4 - Intolerable Eye Fatigue 0 - Never 1 - Tolerable 2 - Uncomfortable 3 - Bothersome 4 - Intolerable Please check if you have experienced these symptoms Today Within the past 72 hours Within past 3 months HiddenResult - SEVERITY of the dry eye symptomsDo you use eye drops and/or ointments? Yes No Name of drops Have you used them today? Yes No How long are they effective? Do the drops last 4 hours? Yes No Do any gels last 12 hours? Yes No Did you use Moisturizers, lotions or creams around eyes today? Yes No Did you use makeup today? Yes No Have you touched/rubbed your eye(s) today? Yes No If yes, when? How? Have you ever been told you have BLEPHARITIS? Yes No STYE? Yes No Do you have fluctuating vision problems (that gets better with BLINKING)? Never Sometimes Frequently A lot/always
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