Speed 2 Test – Dry Eye Name* First Last Phone*Date of Birth MM slash DD slash YYYY Male Female Date 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, 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 Report 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, Grittiness or Scratchiness Never Tolerable Uncomfortable Bothersome Intolerable Soreness or Irritation Never Tolerable Uncomfortable Bothersome Intolerable Burning or Watering Never Tolerable Uncomfortable Bothersome Intolerable Eye Fatigue Never Tolerable Uncomfortable Bothersome Intolerable Please check if you have experienced these symptoms Today Within the past 72 hours Within past 3 months Do you use eye drops and/or ointments? Yes No Have you used them today? Yes No Name of drops How long are they effective? Do the drops last 4 hours? Yes No Do any gels last 12 hours? Yes No Did you use Moisturizer, 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 when? How? Have you ever been told you have BLEPHARITIS? Yes No STYE? Yes No Do you have fluctuating vision problems (that’s gets better with BLINKING) Never Sometimes Frequently A lot/always HiddenTotal Speed Score (Frequency + Severity)Phone
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