Dry Eye Evaluation Form

Filling out the Speed Questionnaire and submitting to our office will help us determine how the Southern Eye Group Dry Eye Clinic can be of most help to you.

*This is a required field






Report the Frequency of your symptoms by checking the appropriate box.

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 daily tasks












 

Contact us at 251-220-8228 to schedule a Dry Eye Consultation today or request an appointment online.