Form – Dry Eye SPEED Questionnaire

Dry Eye SPEED Questionnaire

Todays Date *

Name: *

Birth Date: *

Email Address

Assigned Gender at Birth *

Frequency Section: Dryness, Grittiness or Scratchiness? *

Soreness or Irritation *

Burning or Watering *

Eye Fatigue *

Severity Section: Dryness, Grittiness or Scratchiness? *

Soreness or Irritation *

Burning or Watering *

Eye Fatigue *

Eye Drops *

If "YES", how often? *0 / 100

Total SPEED Score (Frequency + Severity): *