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577 W. Uwchlan Ave. Exton, PA 19341

CALL 610-363-2303 TO SCHEDULE APPOINTMENT

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Home » SPEED™ Questionnaire

SPEED™ Questionnaire

Name*
First Last
Date
MM slash DD slash YYYY
DOB
MM slash DD slash YYYY
Sex:
- M
- F
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:
Symptoms
Dryness, Grittiness or Scratchiness*
- At this visit
- Within past 72 hours
- Within past 3 months
- N/A
Soreness or Irritation*
- At this visit
- Within past 72 hours
- Within past 3 months
- N/A
Burning or Watering*
- At this visit
- Within past 72 hours
- Within past 3 months
- N/A
Eye Fatigue*
- At this visit
- Within past 72 hours
- Within past 3 months
- N/A
2. Report the FREQUENCY of your symptoms using the rating list below:
Symptoms
Dryness, 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:
Symptoms
Dryness, Grittiness or Scratchiness*
- No Problems
- Tolerable - not perfect, but not uncomfortable
- Uncomfortable - irritating, but does not interfere with my day
- Bothersome - irritating and interferes with my day
- Intolerable - unable to perform my daily tasks
Soreness or Irritation*
- No Problems
- Tolerable - not perfect, but not uncomfortable
- Uncomfortable - irritating, but does not interfere with my day
- Bothersome - irritating and interferes with my day
- Intolerable - unable to perform my daily tasks
Burning or Watering*
- No Problems
- Tolerable - not perfect, but not uncomfortable
- Uncomfortable - irritating, but does not interfere with my day
- Bothersome - irritating and interferes with my day
- Intolerable - unable to perform my daily tasks
Eye Fatigue*
- No Problems
- Tolerable - not perfect, but not uncomfortable
- Uncomfortable - irritating, but does not interfere with my day
- Bothersome - irritating and interferes with my day
- Intolerable - unable to perform my daily tasks
4. Do you use eye drops for lubrication?*
- Yes
- No
how often?

Δ

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Boas Vision Associates

577 W. Uwchlan Ave.
Exton, PA 19341

Phone: 610-363-2303
Fax: 610-363-8560
Email: boasvisionassociates@gmail.com
(Do not send personal health information by email.)

Monday: 9:00 AM - 5:00 PM
Tuesday: 9:00 AM - 5:00 PM
Wednesday: 9:00 AM - 5:00 PM
Thursday: 9:00 AM - 5:00 PM
Friday: 9:30 AM - 3:00 PM
Saturday: Closed
Sunday: Closed

By Appointment Only

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CALL 610-363-2303 TO SCHEDULE APPOINTMENT

Boas Vision Associates

Mark B. Boas, OD, MS
Suzanne O. Boas, OD
Marie K. Gwinn, OD
Katherine R. Boas, OD

Speak Field

Boas Vision Associates - Located at 577 W. Uwchlan Ave., Exton, PA 19341. Phone: 610-363-2303. https://www.drboas.com

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