Dry Eye Speed Questionnaire

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

Dryness*

Grittiness or Scratchiness*

Soreness or Irritation*

Burning or Watering*

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*

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*

Grittiness or Scratchiness*

Soreness or Irritation​​​​​​​*

Burning or Watering*

Do you use eye drops for lubrication?

If yes, How often?