SPEED Dry Eye Assessment | Capital Vision Care

Report the FREQUENCY of your symptoms using the rating list below:*

0 = Never 1 = Sometimes 2 = Often 3 = Constant

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

Do you use eye drops for lubrication?*

Yes

No

How often do you use eye drops for lubrication?*

Write Here

First Name

Last Name

Phone

Email Address

When was your last eye exam?*

Less than 6 months ago.

Over 1 year ago.

Over 2 years ago.

Name of optometrist or ophthalmologist?

It's important that follow up appointments are done to manage your dry eyes. We will ensure that your optometrist or ophthalmologist receives your treatment results.

Write Here

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

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

SPEED Dry Eye Assesment

Report the type of SYMPTOMS you experience and when they occur:

Your form has been submitted

About Our Practice

Contact Info – Head Office