SPEED Questionnaire Date* Date Format: MM slash DD slash YYYY Name* First Last Date of Birth* Date Format: MM slash DD slash YYYY Sex* M F Report the FREQUENCY of any dry eye symptoms you are experiencing. Dryness, Grittiness or Scratchiness*NeverSometimesOftenConstantSoreness or Irritation*NeverSometimesOftenConstantBurning or Watering*NeverSometimesOftenConstantEye Fatigue*NeverSometimesOftenConstantReport the SEVERITY of any dry eye symptoms you are experiencing using the grid belowDryness, Grittiness or Scratchiness*No ProblemTolerableUncomfortableBothersomeIntolerableSoreness or Irritation*No ProblemTolerableUncomfortableBothersomeIntolerableBurning or Watering*No ProblemTolerableUncomfortableBothersomeIntolerableEye Fatigue*No ProblemTolerableUncomfortableBothersomeIntolerablePlease mark if you have experienced any of the above symptoms: Today Within the past 72 hrs Within the past 3 months Do you have fluctuating vision problems that improve if you blink? Never Sometimes Frequently A Lot or Always Do your symptoms affect your daily activities? Yes No Which activities seem to make your symptoms worst? Reading Computer Use Close-Up Work Watching TV Outdoor Activities Other How long can you do the activity before your eyes start bothering you?Digital Retinal Imaging and Computerized Visual Field Consent FormOur state-of-the-art diagnostic tools are considered to be "elective" to a comprehensive eye exam, and therefore are not covered by your insurance and a nominal fee of $36 will be added to your charges. Yes, I choose to have retinal imaging and computerized field testing done for an additional $36 Not sure, I would like more information about these tests. No, I choose not to have retinal imaging and computerized field testing done. SignatureDate Date Format: MM slash DD slash YYYY