Filling out the SPEED Questionnaire and submitting it to our office will help us determine how the CAMEN EYE CARE Center can be of most help to you.

Name *

Date *

Email *

Phone *

Age *

Dryness, Grittiness or Scratchiness

0123

Soreness or Irritation

0123

Burning or Watering

0123

Eye Fatigue

0123

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 daily tasks

Dryness, Grittiness or Scratchiness

01234

Soreness or Irritation

01234

Burning or Watering

01234

Eye Fatigue

01234

SUBMIT FORM