Speed II® Dry Eye Questionaire

Dry Eye Disease is more common than most people realize. Please take a moment to carefully complete this questionaire to better enable your eye care provider to help you.

Full Name *

Date *

Email Address *

1. Report the frequency of your symptoms.

Dryness, grittiness, or scratchiness. *

Never

Sometimes

Often

Constant

Soreness or irritation *

Never

Sometimes

Often

Constant

Burning or watering *

Never

Sometimes

Often

Constant

Eye fatigue *

Never

Sometimes

Often

Constant

2. Report the severity of your symptoms.

Dryness, grittiness, or scratchiness. *

No problems

Tolerable

Uncomfortable

Bothersome

Intolerable

Soreness or irritation *

No problems

Tolerable

Uncomfortable

Bothersome

Intolerable

Burning or watering *

No problems

Tolerable

Uncomfortable

Bothersome

Intolerable

Eye fatigue *

No problems

Tolerable

Uncomfortable

Bothersome

Intolerable

3. Please select if you have experienced the above symptoms: *

Today

Within the last 3 days

Within the past 3 months

4. Do you use eye drops for lubrication? *

No

Yes

If yes, how often?

What brand?

5. Do you have fluctuating vision (corrected with blinking)? *

Never

Sometimes

Frequently

Always

6. Have you been told you have blepharitis? *

No

Yes

7. Have you been treated for a stye? *

No

Yes

8. Have you had any of the following symptoms recently? *

Eyelid redness

Crusting around lashes

Lid irritation