Dry Eye Questionnaire
Patient Full Name
Patient Date of Birth (mm/dd/yyyy - ex: 02/06/1999)



Have you experienced any of these symptoms since your last visit:

Questions
Yes/No/?
Blurry vision
Redness
Burning
Itching
Light sensitivity
Excessive tearing/watery eyes
Tired eyes/ eye fatigue
Stringy mucous in or around the eyes
Foreign body sensation
Contact lens discomfort
Scratchy, feeling of sand or grit in the eye
Fluctuating Vision

Have you used any eye drops in the last two hours?




Signature of patient / legal guardian (type your name)
Enter Letters/Number you see:





Office Hours
Mon
9:00 - 5:30
Tue
9:00 - 5:30
Wed
9:00 - 5:30
Thu
9:00 - 5:30
Fri
9:00 - 5:30
Sat
10:00 - 2:00
Sun
Closed
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13768 Roswell Ave.
Suite 208
Chino, CA 91710

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Call (909) 627-2020

Email Us info@shameemkhanod.com
Dr. Shameem Khan Optometrist, Inc. 13768 Roswell Ave. Suite 208 Chino, CA 91710 Phone: (909) 627-2020

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