Explore Our Dry Eye Quiz – Ultimate Eye Care Santa Fe

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

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?*

Yes
No

If yes, 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

Comments

This field is for validation purposes and should be left unchanged.

Dry Eye Quiz

SPEED™ Questionnaire