Skip to main content
Bordering Cedar Park & North Austin, minutes from Lakeline Mall. NW Corner of El Salido Pkwy & 620, behind the Capital One Bank Building.

Call 512-918-EYES(3937) Schedule an Eye Exam Pay My Bill
hero-childpage

Online Patient Forms


Demographics

TitleFirstLastMISuffixNickname
Address: Apt/Suite #:
City: State: ZipCode:


Email: Cell Phone:
Preferred Contact Method:
 
SSN: Sex:
Birthday: Occupation:

Billing Information Is The Billing Address the Same?
TitleFirstLastMISuffix
AddressApt/Suite #
CityStateZipCode
Home Phone:
Work Phone:

Medical Insurance

Insurance Information Please select from the following Medical Insurance plans:
Insurance Name:
Insurance ID:
Insurance Policy Group:

Not Primary on Account:
Primary on Account
Name:Last, First MI
Relationship to Insured:
Sex:
Address:
City: State: Zip:
Phone Number:
DOB:
Employer/School:

Vision Insurance

Insurance Information Please select from the following Vision Insurance plans:
Insurance Name:
Insurance ID:
Insurance Policy Group:

Not Primary on Account:
Primary on Account
Name:Last, First MI
Relationship to Insured:
Sex:
Address:
City: State: Zip:
Phone Number:
DOB:
Employer/School:

Medical History

Last Eye Doctor:
Preferred Pharmacy
Height
ft in
Weight
lbs
Preferred Language
Race
Ethnicity
Smoking Status
Do Your Eyes Sting, Burn, Itch, Or Feel Dry?
Have You Had An Eye Injury Or Been Diagnosed With Cataracts, Lazy Eye, Retinal Problems, Or Glaucoma?
Do You Have a History Of Headaches? Arthritis? Asthma? Diabetes? High Blood Pressure?
Heart Problems? Inflammatory Bowel Disease? Seizures? Thyroid Problems?
Do You Smoke? Are You Pregnant? Are You Nursing? Are You HIV+?
If Yes, Please List Below.
Does Anyone In Your Family Have/Had Diabetes? Lupus? Cancer? High Blood Pressure? Heart Problems? Auto-Immune Disease?
If Yes, Please List Below.
Does Anyone In Your Family Have/Had Glaucoma? Macular Degeneration? Retinal Detachment? Other Retinal Disorders?
If Yes, Please List Below.
Any Other Relevant Information?


Review of Systems

Are you currently experiencing any of the following?

General: Ears/Nose/Throat:
Respiratory: Gastrointestinal:
Genitourinary: Skin:
Musculoskeletal: Neurological:
Psychiatric: Endocrine:
Blood/Lymph: Cardiovascular:
Allergy/Immune: Eyes:
Other:


BVD Review of Systems

Driving:

Cardiovascular:

Ear, Nose, Throat:
Ringing/Tinnitus - Fullness - Sensation of Fluid Leaking -

Neurological:


Psychiatric:

Endocrine:

Eyes:



Other:

Reading Symptoms



If yes, age when first worn:


If yes, age when first worn:


Glasses worn:
If yes, hours per day:


Sound Sensitivity Questionnaire

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?


SSCD Symptom Questionnaire

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?

Submit Data

Call 512-918-EYES(3937) Schedule an Eye Exam Pay My Bill