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Home » Eye Care Services » Dry Eye » Dry Eye Questionnaire

Dry Eye 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 time
- Not at this time
- Within past 72 hours
- Not within past 72 hours
- Within past 3 months
- Not within past 3 months
Soreness or Irritation*
- At this time
- Not at this time
- Within past 72 hours
- Not within past 72 hours
- Within past 3 months
- Not within past 3 months
Burning or Watering*
- At this time
- Not at this time
- Within past 72 hours
- Not within past 72 hours
- Within past 3 months
- Not within past 3 months
Eye Fatigue*
- At this time
- Not at this time
- Within past 72 hours
- Not within past 72 hours
- Within past 3 months
- Not within past 3 months
2. Report the FREQUENCY of your symptoms using the rating list below:

0 = Never
1 = Sometimes
2 = Often
3 = Constant
Dryness, Grittiness or Scratchiness*
- 0
- 1
- 2
- 3
Soreness or Irritation*
- 0
- 1
- 2
- 3
Burning or Watering*
- 0
- 1
- 2
- 3
Eye Fatigue*
- 0
- 1
- 2
- 3
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*
- 0
- 1
- 2
- 3
- 4
Soreness or Irritation*
- 0
- 1
- 2
- 3
- 4
Burning or Watering*
- 0
- 1
- 2
- 3
- 4
Eye Fatigue*
- 0
- 1
- 2
- 3
- 4
4. Do you use eye drops for lubrication?*
- Yes
- No
how often?
Add your name, phone number and email address to see your results:
Name*
First Last
Phone
Email*
New or returning patient?
- New
- Returning
Click to see your SPEED score results.

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Della Porta EyeCare LLC

156 Farmington Ave.
Bristol, CT 06010

Monday: 9:00 AM - 6:00 PM
Tuesday: 9:00 AM - 5:00 PM
Wednesday: 9:00 AM - 5:00 PM
Thursday: 8:00 AM - 5:00 PM
Friday: 8:00 AM - 12:00 PM
Saturday: Closed
Sunday: Closed

We are open on select Saturdays! Please call (860) 512-7222 for appointments.

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Della Porta EyeCare LLC
156 Farmington Ave.
Bristol, CT 06010
Phone: 860-582-0702
https://www.dellaportaeyecare.com

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