Details Before Your Visit (NYC) Details Before Your Visit (NYC) Due to new guidelines for social distancing and limiting interaction time we have implemented new procedures to provide excellent care in a safe environment. Please include details here about the main reason your upcoming visit:Name* First Last Email* Main Reason for visitWhich Eye?Right EyeLeft EyeBoth EyesLocationSelect all that apply Far Vision Near Vision Side Vision Eyeball Eyelid area Top Bottom To my Right To my Left Quality Improving Worsening Unchanged Severity: On a scale of 1-10Choose a level for your complaint: 10 being the worst0 - Resolved (no problem)1 - Very Mild2345678910 - WorstDuration Constant Variable Less than 30 minutes Morning Night Onset Today Yesterday 2 days ago Less than a week 1 month 2 months 3 months More than 4 months ContextWhat is associated with this? Screen time Wearing Contacts Eye Trauma Eye infection Eye surgery Medications Modifying factorsWhat have you done that helps? No relief Close eyes Artificial tears OTC medication/drops Prescription medication/drops Other (described below) Signs and Symptoms: How does it feel and look?Please describe how it feels and looks.Once we have entered all your information we will call to review it and explain what to expect at your next visitPhone*Please confirm the best number to reach you for this call Δ
