SPEED™ Questionnaire | Katonah Eye Care + Aesthetics

1. Report the type of SYMPTOMS you experience and when the occur:

Symptoms	At this visit	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

2. Report the FREQUENCY of your symptoms using the rating list below:

0 = Never 1 = Sometimes 2 = Often 3 = Constant

3. Report the SEVERITY of your symptoms using the rating list below:

0 = No Problems
1 = Tolerable – not perfect, but not comfortable
2 = Uncomfortable – irritating, but does not interfere with my day
3 = Bothersome – irritating and interferes with my day
4 = Intolerable – unable to perform my daily tasks

Do you use eye drops for lubrication?

Yes
No
If yes, how often?