Dry Eye Information Patient Name* First Last HiddenDate MM slash DD slash YYYY Check all symptoms experienced since last visit* Dry Eyes 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 eye Fluctuating Vision None patient appointment date MM slash DD slash YYYY COVID-19 Patient Evaluation QuestionnaireWith the recent spread of COVID-19 we are taking additional steps in order to protect you, our patient as well as our staff. The AAO, AOA and other optometry specific sources continue to provide updated information and recommendations regarding patient care, symptoms and the ongoing efforts to understand and control the spread of COVID-19. For the health and safety of our patients and staff please answer the below questions:Have you or anyone in your household been diagnosed with COVID-19, had a fever, cough, difficulty breathing or cold/flu-like symptoms in the last 2 weeks?* Yes No Are you currently providing care for anyone who has been diagnosed with COVID-19, had a fever, cough, difficulty breathing or cold/flu-like symptoms in the last 2 weeks?* Yes No Are you or anyone in your household currently under involuntary quarantine?* Yes No Are you or anyone in your household currently under involuntary quarantine in the past 2 weeks?* Yes No Patient SignatureParent/Guardian Signature