Patient information

First name

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Last name

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Nickname

Birth Sex (required by insurance)

Male Female

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Pronoun

Address

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Apt/Suite #

City

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State

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Zip Code

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Cell Phone I opt-in to receiving text messages from this office.

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10DLC Privacy Policy
Terms And Conditions

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Preferred Contact Method

Date of Birth

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Last 4 of SSN:

Last Eye Doctor:

Primary Care Physician

Preferred Pharmacy

Medications (including OTC) No Current Medications

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Allergies No Known Drug Allergies

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Occupation

Hobbies

Preferred Language

Smoking Status

Are you experiencing any dry eye symptoms such as stinging or burning?

Have You been diagnosed with any eye conditions or had any eye surgeries? Such as Cataract Surgery, Glaucoma, Macular Degeneration?

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Do You Have a history of any of the following?

If Yes, Please List Below. If No, Please Write No

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If Yes, Please List Below. If No, Please Write No

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Does Anyone In Your Family Have/Had Glaucoma | Macular Degeneration | Retinal Detachment | Other Retinal Disorders?

If Yes, Please List Below. If No, Please Write No

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Any Other Relevant Information?

Do your eyes get tired or feel eye strain, especially after prolonged computer use?

Yes

If yes, when?

1 = Never 2 = Rarely 3 = Sometimes 4 = Very Often 5 = Always

I get headaches of any severity each week (dull ache counts)

My headaches get worse later in the day

I have stiffness / tension in my neck / shoulders when i work on a computer or read

My eye feel increasingly fatigued / tired as the day goes on

I experience dizziness, motion sickness or vertigo

Instructions: For each question, please choose the answer that best applies to you.

1. Do you ever use earplugs or earmuffs to reduce your noise perception?
(Do not consider the use of hearing protection during abnormally high noise exposure situations)

2. Do you find it harder to ignore sounds around you in everyday situations?

3. Do you have trouble reading in a noisy or loud environment?

4. Do you have trouble concentrating in noisy surroundings?

5. Do you have difficulty listening to conversations in noisy places?

6. Has anyone you know ever told you that you tolerate noise or certain kinds of sound badly?

7. Are you particularly sensitive to or bothered by street noise?

8. Do you find the noise unpleasant in certain social situations?
(e.g. night clubs, pubs or bars, concerts, firework displays, cocktail receptions)

9. When someone suggests doing something, do you immediately think about the noise you're going to have to face?
(going out, to the cinema, to a concert, etc.)

10. Do you ever turn down an invitation or not go out because of the noise you would have to face?

11. Do noises or particular sounds bother you more in a quiet place than in a slightly noisy room?

12. Do stress and tiredness reduce your ability to concentrate in noise?

13. Are you less able to concentrate in noise towards the end of the day?

14. Do noise and certain sounds cause you stress and irritation?

1. Do you experience dizziness or notice an increase in dizziness when speaking in a loud voice or in response to loud noises?

2. Do people mention to you that your speaking voice is soft even though it seems loud to you?

3. Have you ever yelled and felt like you were going to pass out?

4. Do your eyes hurt to move up and down, side to side, or feel like they are scraping or dragging while moving?

5. Have people commented that your eyes twitch or do you feel them twitching?

6. Can you hear your own hear beat inside your head when lying down on one side, when having a severe dizzy episode, or during physical exertion?

7. Do you have a feeling of fullness in one or both ears?

8. When you hum or sing, can you see things move or does it make you dizzy?

9. When you cough or sneeze, do you feel like things are moving or does it make you dizzy?

10. Do you get dizzy when lifting heavy objects or when exerting yourself through exercise?

11. Do you sense that objects on the horizon seem to "bounce" in your field of vision while walking or running?

12. Have you ever had the feeling that fluid was leaking out of one of your ears, yet there wasn't any fluid there?

13. Have you ever felt dizzy when there was a storm front passing through and there was a noticeable change in barometric pressure?

14. Do you feel a constant sway in your body?

15. Do you have ringing or crackling in one or both ears?

16. Do you experience dizziness or fullness when lying flat?

Policies, Consent, Submit Data

We Will Not Receive Your Information Until You Press The Green Submit Button Below.

Entering your First and Last name under Patient Signature below acknowledges that you have read and accepted our notice of privacy practices and understand that you will receive your glasses prescription at the end of your exam. Your glasses prescription will also be available through your patient portal.

Notice of Privacy Practices

View Notice of Privacy Practices Form

Neuro Vision Austin Pediatric

Neuro Vision Austin Adult

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Date:

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