Elora Optometry

Dry Eye Questionnaire

BOOK YOUR APPOINTMENT

Dry Eye Questionnaire

Name(Required)
Date(Required)
Date of Birth(Required)

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:

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?(Required)

EYE CARE SERVICES

VISIT OUR OFFICE

Your Vision, Our Mission

We are committed to providing you with great vision. Visit us today!

Where to Park

Access from Victoria Street – parking is available behind the building. The elevator access from the parking lot.

Our Address

54 Victoria St. Unit 201
Elora, ON N0B 1SO

Contact Information

Phone: 519-846-0030
Fax: 519-846-8536

Hours of Operation

Monday
9 AM5 PM
Tuesday
8 AM7 PM
Wednesday
8 AM5 PM
Thursday
9 AM7 PM
Friday
9 AM4 PM
Saturday
By Appointment Only
Sunday
Closed

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