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Billing information
Yes
No
Do you have trouble driving during the day or anxiety while doing so?
Do you have trouble driving during the night or anxiety while doing so?
Do you get motion sickness while in a car?
Syncope / Fainting
Dysautonomia / POTS
Arrhythmia / Palp / Irreg HB
Nausea
BPPV
Meniere's
TMJ
Sleep Apnea
Sinus Disorders
Sinus Pain / Pressure
Dizziness
Vertigo
Migraines
Severe Headaches (other than migraines)
Diplopia
TBI
Feeling Uncoordinated
Epilepsy / Seizures
Stroke / CVA
CN Palsy
Anxiety
Panic Episodes
Depression
ADD / ADHD
PTSD
Agoraphobia
Thyroid Disorder
Adrenal Disorder
Diabetes
Itchiness
Spots / Floaters
Dryness
Gritty feeling
Burning
Eye strain
Sore eyes
Flashes of Light
Increased tearing
Trouble seeing at night
Trouble working up close
Sudden loss of vision
Redness
Watery
Trouble being fit with / adjusting to prior glasses
C Spine Fracture
C Spine Fusion
Neck Pain
I wear glasses
Full time
Part time
Far only
Near only
Both
I wear contact lenses
I work on a computer
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