SPEED DRY EYE QUESTIONNAIRE Patient Name: First Last Date MM slash DD slash YYYY Please answer the following questions by checking the box that best represents your answer. Select only one answer per question1. Report the type of SYMPTOMS you experience and when they occur:Dryness, Grittiness or ScratchinessAT THIS VISIT Yes No WITHIN PAST 72 HOURS Yes No WITHIN PAST 3 MONTHS Yes No Soreness or IrritationAT THIS VISIT Yes No WITHIN PAST 72 HOURS Yes No WITHIN PAST 3 MONTHS Yes No Burning or WateringAT THIS VISIT Yes No WITHIN PAST 72 HOURS Yes No WITHIN PAST 3 MONTHS Yes No Eye FatigueAT THIS VISIT Yes No WITHIN PAST 72 HOURS Yes No WITHIN PAST 3 MONTHS Yes No 2. Report the FREQUENCY of your symptoms using the rating listDryness, 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 3. Report the SEVERITY of your symptoms using the rating list below:Dryness, Grittiness or Scratchiness 0 1 2 3 4 Soreness or Irritation 0 1 2 3 4 Burning or Watering 0 1 2 3 4 Eye Fatigue 0 1 2 3 4 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 4. Do you use eye drops for lubrication? Yes No how often?