SPEED Questionnaire

Symptoms	Today	Within Past 72 Hours	Within Past 3 Months
Dryness, Grittiness or Scratchiness	Yes No	Yes No	Yes No
Soreness or Irritation	Yes No	Yes No	Yes No
Burning or Watering	Yes No	Yes No	Yes No
Eye Fatigue	Yes No	Yes No	Yes No

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. 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?

YesNo

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

YesNo

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 541-882-2812 Make sure to ask our team about receiving coverage through your medical and/or vision insurance.

Thank You!

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SPEED Questionnaire

SPEED Questionnaire

SPEED Questionnaire

SPEED Questionnaire