Skip to main content

For more information and up-to-date COVID-19 Procedures and Protocols, please click HERE. Order Contacts Online or Email Us or call 314-375-2255 for all other inquiries.

Located in the Lenscrafters in the St. Louis Galleria

Call 314-375-2255

Book Appointment

Order Contact Lens

Patient History Form

Hours & Location
Clinic
Advanced Services
Services
- Comprehensive Eye Exams
Eye Doctors
Contact Lenses
- Scleral Lenses
- ACUVUE® OASYS with Transitions
Insurance
Payments

Hours & Location
Clinic
Advanced Services
Services
- Comprehensive Eye Exams
Eye Doctors
Contact Lenses
- Scleral Lenses
- ACUVUE® OASYS with Transitions
Insurance
Payments

Home » Eye Care Services » Dry Eye » SPEED™ Questionnaire

SPEED™ Questionnaire

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.

1. Report the type of SYMPTOMS you experience and when they occur:
Dryness, Grittiness or Scratchiness*
- At this time
- Not at this time
- Within past 72 hours
- Not within past 72 hours
- Within past 3 months
- Not within past 3 months
Soreness or Irritation*
- At this time
- Not at this time
- Within past 72 hours
- Not within past 72 hours
- Within past 3 months
- Not within past 3 months
Burning or Watering*
- At this time
- Not at this time
- Within past 72 hours
- Not within past 72 hours
- Within past 3 months
- Not within past 3 months
Eye Fatigue*
- At this time
- Not at this time
- Within past 72 hours
- Not within past 72 hours
- Within past 3 months
- Not within past 3 months
2. Report the FREQUENCY of your symptoms using the rating list below:

0 = Never
1 = Sometimes
2 = Often
3 = Constant
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 tasks
Dryness, Grittiness or Scratchiness*
- 0
- 1
- 2
- 3
- 4
Soreness or Irritation*
- 0
- 1
- 2
- 3
- 4
Burning or Watering*
- 0
- 1
- 2
- 3
- 4
Eye Fatigue*
- 0
- 1
- 2
- 3
- 4
4. Do you use eye drops for lubrication?*
- Yes
- No
how often?
Add your name, phone number and email address to see your results:
Name*
First Last
Phone
Email*
New or returning patient?
- New
- Returning
Click to see your SPEED score results.

Book An Appointment

Order Contacts Lenses Online

Patient History Form

Antoine Eye Care

Phone: 314-944-8844
Fax: 833-233-4128

2493 St. Louis Galleria
St. Louis, MO 63117

Monday: 10:00 AM - 7:00 PM
Tuesday: 10:00 AM - 7:00 PM
Wednesday: 10:00 AM - 7:00 PM
Thursday: 10:00 AM - 7:00 PM
Friday: 10:00 AM - 7:00 PM
Saturday: 10:00 AM - 7:00 PM
Sunday: 11:00 AM - 4:30 PM

Home
Contact Us
Disclaimer
Privacy Policy

Home
Contact Us
Disclaimer
Privacy Policy

Schedule Appointment

Speak Field

Antoine Eye Care
2493 St. Louis Galleria
St. Louis, MO 63117
Phone: 314-944-8844
https://www.antoineeyecare.com

Powered by EyeCarePro.com
The materials and articles contained on this website are copyrighted and protected under Title 17 of the United States Code
Email Accessibility | Website Accessibility | Sitemap | Privacy | Disclaimer | Login