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Dr. Edward C. Appelman, O.D.
Dr. Amy Mackey Carenza, O.D.
Designer Eyewear
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Toric Contact Lenses For Astigmatism
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Foreign Body Removal
Pink Eye (Conjunctivitis) Treatment
Red Eye Evaluation & Treatment
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Patientforms
Dryeyequestionnaire.Aspx
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
Yes
No
Redness
Yes
No
Burning
Yes
No
Itching
Yes
No
Light sensitivity
Yes
No
Excessive tearing/watery eyes
Yes
No
Tired eyes/ eye fatigue
Yes
No
Stringy mucous in or around the eyes
Yes
No
Foreign body sensation
Yes
No
Contact lens discomfort
Yes
No
Scratchy, feeling of sand or grit in the eye
Yes
No
Fluctuating Vision
Yes
No
Have you used any eye drops in the last two hours?
Yes
No
Signature of patient / legal guardian (type your name)
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