Speed Ii Questionnaire Template (Dry Eye Disease)
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1
2For office use only:
Total Speed Score (Frequency + Severity) =_______
SPEED II Questionnaire
Name: _____________________, _________________
Date: _____/_____/_______
(Last)
(First)
Date of Birth: ______/______/_______
Sex: M F (Circle)
Dry Eye Disease is the most frequent reason that 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 questionnaire below.
Report the FREQUENCY of dry eye symptoms you are experiencing by checking Never,
Sometimes, Often or Constant using the numbering system below:
0 = Never, 1 = Sometimes, 2 = Often, 3 = Constant
SYMPTOMS
0
1
2
3
Dryness, Grittiness or Scratchiness
Soreness or Irritation
Burning or Watering
Eye Fatigue
Report the SEVERITY of your symptoms using the ratings list below:
0 = No problems
1 = Tolerable – not perfect but not uncomfortable
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
SYMPTOMS
0
1
2
3
4
Dryness, Grittiness or Scratchiness
Soreness or Irritation
Burning or Watering
Eye Fatigue
Please mark with an X if you have experienced symptoms:
1) Today _____ 2) Within the last past 72 hours _____ 3) Within past 3 months_____
Do you use eye drops and/or ointment? YES NO (Circle) Today? Y N
If yes, which drops do you use?___________________________ Last 4 hours? Y
N
Any Gels Last 12 Hours? Y N Moisturizers, Lotion & Facial Creams Today? Y
N
Have you touched/rubbed your eye(s) today?? If so when & show us how you rub them
How long ago did you touch/rub them?
Any make up today?
Y N
What Omegas do you take?____________________ Do you have Punctal plugs? Y N
Have you been told that you have blepharitis or have you been treated for a stye?
Blepharitis
YES NO (Circle)
Stye
YES NO (Circle)
Do you have fluctuating vision problems? ( That can be corrected with blinking)
Circle: Never
Sometimes
Frequently
A Lot/Always
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Parent category: Life