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SPEED™ Questionnaire

SPEED™ Questionnaire


  • For the Standardized Patient Evaluation of Eye Dryness (SPEED) Questionnaire, please answer the following questions by checking the box that best represents your answer. Select only one answer per question.

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

  • 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 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
  • Add your name, phone number and email address to see your results:

  • Click “submit” to see your SPEED score results.

Vision Therapy Assessment Referral Form

  • Section 1: Referring Healthcare Provider

  • Date Format: DD slash MM slash YYYY
  • Section 2: Patient Information

  • Date Format: DD slash MM slash YYYY
  • Refraction & BCVA:
  • Refraction & BCVA: