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Slide 104 Plumtree Road Suite 107 | Bel Air, MD 21015 | (410) 870-7942 | New Patient Paperwork
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Eye Dryness Questionnaire

Below is a questionnaire designed by TearScience to help evaluate eye dryness. Called SPEED, (Standardized Patient Evaluation of Eye Dryness) this questionnaire will be reviewed by an Advanced Eye Care physician.

In the event you are at risk for dry eye syndrome, you will be contacted by a service representative at Advanced Eye Care and asked if you would like to have your eyes evaluated.

    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:

    Today




    Within Past 72 Hours




    Within Past 3 Months





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




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



    4. Do you use eye drops for lubrication?

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    104 Plumtree Road
    Suite 107
    Bel Air MD 21015
    (410) 569-7173