Speed 2 Test – Dry Eye Name* First Last Phone*Date of Birth Date Format: MM slash DD slash YYYY MaleFemaleDate Date Format: 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 ScratchinessNeverSometimesOftenConstant Soreness or IrritationNeverSometimesOftenConstant Burning or WateringNeverSometimesOftenConstant Eye FatigueNeverSometimesOftenConstant 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 ScratchinessNeverTolerableUncomfortableBothersomeIntolerableSoreness or IrritationNeverTolerableUncomfortableBothersomeIntolerableBurning or WateringNeverTolerableUncomfortableBothersomeIntolerableEye FatigueNeverTolerableUncomfortableBothersomeIntolerablePlease 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?YesNoHave you used them today?YesNoName of dropsHow long are they effective?Do the drops last 4 hours?YesNoDo any gels last 12 hours?YesNoDid you use Moisturizer, lotions or creams around eyes today?YesNoDid you use makeup today?YesNoHave you touched/rubbed your eye(s) today?YesNowhen?How?Have you ever been told you have BLEPHARITIS?YesNoSTYE?YesNoDo you have fluctuating vision problems (that’s gets better with BLINKING) Never Sometimes Frequently A lot/always Total Speed Score (Frequency + Severity)Phone
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