• 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

  • 1. Do you have headaches and / or facial pain?*
  • 2. Do you have pain in your eyes with eye movement?*
  • 3. Do you experience neck or shoulder discomfort?*
  • 4. Do you have dizziness and / or lightheadedness?*
  • 5. Do you experience dizziness, light-headedness, or nausea while performing close-up activities (i.e. - computer work, reading, writing)?*
  • 6. Do you experience dizziness, light-headedness, or nausea while performing far-distance activities (i.e. - driving, television, movies)?*
  • 7. Do you experience dizziness, light-headedness, or nausea when bending down and standing back up, or when getting up quickly from a seated position?*
  • 8. Do you feel unsteady with walking, or drift to one side while walking?*
  • 9. Do you feel overwhelmed or anxious while walking in a large department store (i.e. – Target, Wal-Mart, etc.)?*
  • 10. Do you feel overwhelmed or anxious when in a crowd?*
  • 11. Does riding in a car make you feel dizzy or uncomfortable?*
  • 12. Do you experience anxiety or nervousness because of your dizziness?*
  • 13. Do you ever find yourself with your head tilted to one side?*
  • 14. Do you experience poor depth perception or have difficulty estimating distances accurately?*
  • 15. Do you experience double / overlapping / shadowed vision at far distances?*
  • 16. Do you experience double / overlapping / shadowed vision at near distances?*
  • 17. Do you experience glare or have sensitivity to bright lights?*
  • 18. Do you close or cover one eye with near or far tasks?*
  • 19. Do you skip lines or lose your place while reading (do you use your finger or a ruler or other guides to maintain your position on the page)?*
  • 20. Do you tire easily with close-up tasks (computer work, reading, writing)?*
  • 21. Do you experience blurred vision with far-distance activities (i.e. - driving, television, movies, chalkboard at school)?*
  • 22. Do you experience blurred vision with close-up activities (i.e. - computer work, reading, writing)?*
  • 23. Do you blink to clear up distant objects after working at a desk or working with close-up activities (i.e. - computer work, reading, writing)?*
  • 24. Do you experience words running together with reading?*
  • 25. Do you experience difficulty with reading or reading comprehension?*

  • Part 2: Level of Discomfort

    On an average day, how much are you bothered by the 8 symptoms listed below? (Rate each symptom from 0 to 10, where 10 is the worst it could be, and where 0 means you have none of that symptom)

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  • On an average day, are you bothered by the following symptoms listed below?

  • Do you have a fast heart rate / palpitations upon standing?*
  • Do you have an intolerance to heat?*
  • Does standing make your dizziness symptoms worse?*
  • If you lie down, is your dizziness reduced?*
  • Do you experience dizziness or notice an increase in dizziness when speaking loudly or in response to loud noises?*
  • Do people mention to you that your speaking voice is soft even though it seems loud to you?*
  • When you cough or sneeze do you feel like things are moving or does it make you dizzy?*
  • Have you ever had the feeling that fluid was leaking out of one of your ears, yet there wasn’t any fluid there?*
  • Are you made uncomfortable by sounds that seem loud to you but not to your friend/ family?*
  • Is your dizziness worse with head movement, particularly when rolling over in bed?*

  • Part 3: History

    Have you ever been diagnosed with or experienced...

  • Traumatic Brain Injury / Concussion*
  • Reading Disability*
  • Lazy Eye*
  • Have you ever had an eye operation?*
  • How did you find us?*

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

    All of your personal information will be stored securely and kept 100% private.
  • Have You Been To The Practice Before?*
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Date of Birth*
     - -

  • Address

  • 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).
  • Do you have medical insurance or a vision plan?*

  • Primary Medical Insurance

  • Medical Insurance Primary Holder's Date of Birth*
     - -

  • Vision Insurance

  • Should be Empty: