Lakeline NeuroVisual

Please note: This questionnaire is for those 14 years old or older.
If you are 13 years old or younger, please click here.

If you would like to tell us more about your symptoms, please write about them in the Comment Section at the end of the Questionnaire. We will combine this information with the responses you gave in the Questionnaire to provide you with a more detailed interpretation of the results.
Please Note: We will not sell or otherwise use the information on this form except in addressing your inquiry.
(*) indicates a required field.

Directions: For each of the following questions, please check the answer that best describes your situation. If you wear glasses or contact lenses, answer the questions assuming that you are wearing them. Please answer every question.

•Never = Never
•Occasionally = Less than 1 time / week
•Frequently = At least 1 time / week
•Always = Everyday

To help us better serve you, please provide the following information:

All of your personal information will be stored securely and kept 100% private.
New PatientReturning Patient
Your First Name*
Your Last Name*
Email*
example@example.com
Best Phone Number*
Format: (000) 000-0000.
Back-Up Phone Number*
Format: (000) 000-0000.
Date of Birth*

MonthDayYear
Date
Address
Street Address*
Street Address Line 2
City*
State / Province*
Postal / Zip Code*
Insurance Information

By sharing this information with us, you are enabling us to provide an accurate quote for the cost of care based on your insurance plan(s).
I have medical insurance.I have a vision plan.I have both.I have no insurance or vision plan.
Primary Medical Insurance
Name of Insurance Provider*
Medical Insurance ID #*
Medical Insurance Group #*
Medical Insurance Primary Holder's First Name*
Medical Insurance Primary Holder's Last Name*
Medical Insurance Primary Holder's Date of Birth*

MonthDayYear
Date
Vision Insurance
Name of Vision Insurance Provider**
Vision Insurance ID #**
Vision Insurance Group #**
Vision Insurance Primary Holder's First Name*
Vision Insurance Primary Holder's Last Name*
BVDQ Calculation*
SSI Calculation*
Should be Empty:

Part 2: Level of Discomfort