Do you think you have Dry Eye? Take our questionnaire below and submit it to find out!

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.

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

Dryness, Grittiness or Scratchiness*

Soreness or Irritation*

Burning or Watering*

Eye Fatigue*

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*

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*


Do you use eye drops for lubrication?*


If yes, how often?

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


New or returning patient?

Download SPEED Questionnaire​​​​​​​

  • If you do not already have AdobeReader® installed on your computer, Click Here to download it now.

  • Download the necessary form(s), print it out and fill in the required information.

  • Fax or email us your completed form(s) or bring it with you to your appointment.

Upload your form below:

Upload completed form here:

12345 none optometrist # # # https://goo.gl/maps/iUGoa2KzhgBvcXcd6 https://goo.gl/maps/Sev3tg4uWNTyBMPu6 https://goo.gl/maps/B7i8ELpvV2tE5k5W6 9:00 AM to 5:00 PM 8:00 AM to 4:00 PM 9:00 AM to 6:00 PM 8:00 AM to 4:00 PM 8:00 AM to 1:00 PM Closed Closed 6088330062 503 Commerce Drive Madison WI 53719 9:00 AM to 5:00 PM 9:00 AM to 5:00 PM 8:00 AM to 4:00 PM 9:00 AM to 5:00 PM 9:00 AM to 12:00 PM Closed Closed 9206482011 395 W Tyranena Park Rd, Unit #5 Lake Mills WI 53551 8:30 AM to 5:00 PM 8:30 AM to 6:00 PM 8:30 AM to 4:00 PM 8:30 AM to 5:00 PM 8:30 AM to 12:00 PM Closed Closed 9203243501 102 Shaler Drive Waupun WI 53963