Skip to main content

Just North of Horsetooth on Shields St. in Fort Collins, CO

Hours & Location
Eye Care Center
Eye Care Services
Dry Eye Center of Excellence
Eyeglass Boutique
- Eyeglasses
- Designer Frames
Contact Lenses
- Scleral Contact Lenses
Insurance Information

Hours & Location
Eye Care Center
Eye Care Services
Dry Eye Center of Excellence
Eyeglass Boutique
- Eyeglasses
- Designer Frames
Contact Lenses
- Scleral Contact Lenses
Insurance Information

Clearly, Our Focus Is On You!

Request An Appointment

Call Now! 970-276-6060

Hours & Location
Eye Care Center
Eye Care Services
Dry Eye Center of Excellence
Eyeglass Boutique
- Eyeglasses
- Designer Frames
Contact Lenses
- Scleral Contact Lenses
Insurance Information

Hours & Location
Eye Care Center
Eye Care Services
Dry Eye Center of Excellence
Eyeglass Boutique
- Eyeglasses
- Designer Frames
Contact Lenses
- Scleral Contact Lenses
Insurance Information

Hours & Location
Eye Care Center
Eye Care Services
Dry Eye Center of Excellence
Eyeglass Boutique
- Eyeglasses
- Designer Frames
Contact Lenses
- Scleral Contact Lenses
Insurance Information

Hours & Location
Eye Care Center
Eye Care Services
Dry Eye Center of Excellence
Eyeglass Boutique
- Eyeglasses
- Designer Frames
Contact Lenses
- Scleral Contact Lenses
Insurance Information

Menu

Call

Home » SPEED Questionnaire

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*
- Never
- Sometimes
- Often
- Constant
Soreness or Irritation*
- Never
- Sometimes
- Often
- Constant
Burning or Watering*
- Never
- Sometimes
- Often
- Constant
Eye Fatigue*
- Never
- Sometimes
- Often
- Constant
Report the SEVERITY of any dry eye symptoms you are experiencing using the grid below
Dryness, Grittiness or Scratchiness*
- No Problem
- Tolerable
- Uncomfortable
- Bothersome
- Intolerable
Soreness or Irritation*
- No Problem
- Tolerable
- Uncomfortable
- Bothersome
- Intolerable
Burning or Watering*
- No Problem
- Tolerable
- Uncomfortable
- Bothersome
- Intolerable
Eye Fatigue*
- No Problem
- Tolerable
- Uncomfortable
- Bothersome
- Intolerable
Please 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 Form
Our 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.
Signature
Date
Date Format: MM slash DD slash YYYY

Northern Colorado's Dry Eye Specialists

Search:

Request Appointment

Contact Lens Store

Read Our Reviews

Follow Us

20/20 Vision Center

Phone: (970) 490-2020
Fax: (970) 221-3121
Email: reception@2020visioncenter.com
(Do not send personal health information by email.)

3501 S. Shields St.
Fort Collins, CO 80526

Monday: 9:00 AM - 5:00 PM
Tuesday: 9:00 AM - 5:00 PM
Wednesday: 9:00 AM - 5:00 PM
Thursday: 10:00 AM - 7:00 PM
Friday: 9:00 AM - 5:00 PM
Saturday: Closed
Sunday: Closed

Find Us Here

20/20 Vision Center - Located at 3501 S Shields St., Fort Collins, CO, 80526. Phone: 970-490-2020. https://www.2020visioncenter.com/

We are Social

Important Links

Home
Contact Us
Privacy Policy
Sitemap

Home
Contact Us
Privacy Policy
Sitemap

Quick Links

Hours & Location
Eye Care Center
Eye Care Services
Dry Eye Center of Excellence
Eyeglass Boutique
Contact Lenses
Insurance Information

Hours & Location
Eye Care Center
Eye Care Services
Dry Eye Center of Excellence
Eyeglass Boutique
Contact Lenses
Insurance Information

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