Book Appointment (479) 521-6460

Location

Book Appointment (479) 521-6460

Location

Dry Eye Questionnaire

Dry Eye 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:

Dryness, Grittiness or Scratchiness
Soreness or Irritation
Burning or Watering
Eye Fatigue

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

0 = Never

1 = Sometimes

2 = Often

3 = Constant

Dryness, Grittiness or Scratchiness
Soreness or Irritation
Burning or Watering
Eye Fatigue

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

Dryness, Grittiness or Scratchiness
Soreness or Irritation
Burning or Watering
Eye Fatigue
4. Do you use eye drops for lubrication?

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

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New or returning patient?

Please do not submit any Protected Health Information (PHI).

EyeLove Family Eye Care & Optical

Address

4362 North Waterside Court #110,
Fayetteville, AR 72703

Phone

(479) 521-6460

We look forward to hearing from you

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Please do not submit any Protected Health Information (PHI).

Our Hours

Monday  

8:00 am - 5:00 pm

Tuesday  

8:00 am - 5:00 pm

Wednesday  

8:00 am - 5:00 pm

Thursday  

8:00 am - 5:00 pm

Friday  

8:00 am - 12:00 pm

Saturday  

Closed

Sunday  

Closed

  • Address

    4362 North Waterside Court #110,
    Fayetteville, AR 72703 US

(479) 521-6460