2300 S. Congress Ave. Suite 102 Boynton Beach, FL 33426

(561) 742-1944

Consultation Request
Patient Information
Insurance Information
Dilation Information
Health History

Financial Policy
Acknowledgment of Privacy Practice
Authorization to Disclose Health Information
Order Contacts
Dry Eye Questionnaire

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)

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2300 S. Congress Ave.
Suite 102
Boynton Beach, FL 33426

(561) 742-1944

OFFICE HOURS

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

Boynton Eye Institute, P.A. 2300 S. Congress Ave. Suite 102 Boynton Beach, FL 33426 Phone: (561) 742-1944 Fax: (561) 742-0525

Boynton Eye Institute P.A. proudly serves Boynton Beach and the surrounding areas of Lake Worth, Delray Beach, Boca Raton, Greenacres, Canyon Lakes, Palm Springs, Ocean Ridge and Aberdeen.