Elora Optometry

Dry Eye Questionnaire

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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

ADULT & SENIOR EYE EXAMS

ADULT & SENIOR EYE EXAMS

Our vision often deteriorates as we get older, so you want to stay ahead of potential vision issues before they become problematic. We can help you set your sights on healthy vision.
ADULT & SENIOR EYE EXAMS

CHILDREN’S EYE EXAMS

CHILDREN’S EYE EXAMS

Most vision problems begin to develop at a young age, but your child might not know their vision could be getting worse. A simple eye exam with us can ensure great eyesight for your child for years to come.
CHILDREN’S EYE EXAMS

DRY EYE THERAPY

DRY EYE THERAPY

Dry eyes can happen for a variety of reasons, and nobody experiences dry eyes quite the same way. At Elora Optometry, we help diagnose and treat the root cause of your dry eye symptoms so you can get back to what matters most to you.
DRY EYE THERAPY

CONTACT LENS EXAMS & FITTINGS

CONTACT LENS EXAMS & FITTINGS

More and more patients are turning to contacts instead of glasses. Contacts can offer the same benefits glasses can while also offering a variety of features designed to manage various vision problems.
CONTACT LENS EXAMS & FITTINGS

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 AM – 5 PM
Tuesday
8 AM – 7 PM
Wednesday
8 AM – 5 PM
Thursday
9 AM – 7 PM
Friday
9 AM – 4 PM
Saturday
By Appointment Only
Sunday
Closed
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