VT Patient Forms

Convergence Insufficiency Symptom Survey (CISS)

Any patient seeking vision therapy, adults and children.

Young Child History Form

For any patients, aged 0-4 who are seeking vision therapy.

School Age Child History Form

For any patients, attending school (K-12), who are seeking vision therapy.

Adult History Form

For any adult patients who are seeking vision therapy.

Head Trauma History Form

For any patients suffering from head trauma, seeking vision therapy.

Brain Injury Vision Symptom Survey (BIVSS)

Any patient seeking vision therapy due to a brain injury.

Dizziness Handicap Inventory (DHI)

For any patient seeking vision therapy who suffer from dizziness.

Migraine Disability Assessment Questionnaire (MIDAS)

For any patient seeking vision therapy who suffer from migraines.

Please submit completed forms by mail, fax, email, or online at least one week before your scheduled appointment.

Email:
grace@superioreye.com

Fax:
906-225-0460
Attn: Grace

Mail:
Superior Eye Health, Attn: Grace
2822 Venture Drive
Marquette, MI 49855