Dry Eye Questionnaire Name(Required) First Last Date(Required) Month Day Year Date of Birth(Required) Month Day Year 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 At this visit Within past 72 hours Within past 3 months Soreness or Irritation At this visit Within past 72 hours Within past 3 months Burning or Watering At this visit Within past 72 hours Within past 3 months Eye Fatigue At this visit Within past 72 hours Within past 3 months 2. Report the FREQUENCY of your symptoms using the rating list below:Dryness, Grittiness or Scratchiness 0 1 2 3 Soreness or Irritation 0 1 2 3 Burning or Watering 0 1 2 3 Eye Fatigue 0 1 2 3 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 tasksDryness, Grittiness or Scratchiness 0 1 2 3 Soreness or Irritation 0 1 2 3 Burning or Watering 0 1 2 3 Eye Fatigue 0 1 2 3 4. Do you use eye drops for lubrication?(Required) Yes No If yes, how often?