Dry Eye Patient Daily Tracking Form

We are collecting a waiting list for patients so we can prioritize your visit properly. Dry Eye Disease is the most frequent reason that patients visit eye doctors. We ask that you take a few moments and thoughtfully complete the validated questionnaire below as a measure of your symptoms.
What's your name?*

First NameLast Name
Date of Birth

MonthDayYear
Your Email
example@example.com
Your Cell Phone Number

Area CodePhone Number
Your Address (optional)

Street Address

Street Address Line 2

CityState / Province

Zip CodeCountry

1. Report the FREQUENCY of dry eye symptoms you are experiencing by checking Never, Sometimes, Often or Constant using the numbering system below: 0 = Never, 1 = Sometimes, 2 = Often, 3 = Constant*

	0	1	2	3
Dryness, Grittiness or Scratchiness
Soreness or Irritation
Burning or Watering
Eye Fatigue

Number
(A) Total Frequency Score from above (please add your total score from above)
(A) Maximum score(12)

2. Report the SEVERITY of dry eye symptoms you are experiencing using the numbering system 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

	0	1	2	3	4
Dryness, Grittiness or Scratchiness
Soreness or Irritation
Burning or Watering
Eye Fatigue

(B) Total Severity Score from above (please add your total score from above)
TOTAL SYMPTON SCORE =

The Standardized Patient Evaluation of Eye Dryness (SPEED) Questionnaire is a validated symptom test to screen for possible dry eye disease (DED) and meibomian gland dysfunction (MGD). Your score was greater then 6. A SPEED score of 6 or greater is highly correlated to the presence of one or both of these conditions. A thorough dry eye consultation can determine the underlying cause(s) of your symptoms and allow for appropriate treatment to address and improve this chronic condition.

What Dry Eye Service are you interested in?

Dry Eye ConsultationLipiFlowIntense Pulsed LightClinical Eyelid CleaningAmniotic Membrane TransferIntraductal MG ProbingOther (please specify)

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