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)

Captcha:

Enter Letters/Number you see:

4810 Lakeland Dr.
Flowood, MS 39232
(601) 939-6366

HOURS OF OPERATION

Monday

8:00am - 5:30pm

Tuesday

8:00am - 5:30pm

Wednesday

8:00am - 5:30pm

Thursday

8:00am - 5:30pm

Friday

8:00am - 5:30pm

Saturday

Closed

Sunday

Closed

The Optical Shoppe 4810 Lakeland Dr. Flowood, MS 39232 Phone: (601) 939-6366