Lakeline NeuroVisual

Please note: This questionnaire is for someone younger than 14 years old.
If you are 14 years old or older, 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 verify that you are human*

Please help us help others by using this box to be very specific about how you found us:
How did you find us?*

Internet SearchReferred by a FriendReferred by a ProfessionalFound us in a forum, blog, or social mediaFacebookOther
Please explain:*
Examples include:If you found us by Internet search, what key words did you use? If you were referred, who specifically referred you? If you found out about us on a blog or forum or social media site, specifically which one was it? Other: Please explain | Heard about us - where?

To help us better serve you, please provide the following information:
Have You Been To The Practice Before?*

New PatientReturning Patient
Child's First Name*
Child's Last Name*
Parent / Guardian's First Name*
Parent / Guardian's Last Name*
Email*
example@example.com
Parent / Guardian's Best Phone Number*
Parent / Guardian's Back-Up Phone Number*
Date of Birth*

MonthDayYear
Date
Street Address*
City*
State / Province*
Postal / Zip Code*
Do you have medical insurance or a vision plan?*

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 Score
SSI Score
Should be Empty:

Previous Diagnosis