Patient Symptom Surveys

Convergence Insufficiency Symptom Survey (CISS)
$0.00

Any patients seeking vision therapy are required to fill out this survey and submit it at least one week before their scheduled appointment.

Migraine Disability Assessment Questionnaire (MIDAS)
$0.00

Any patients seeking vision therapy who suffer from migraines should fill this out and submit it at least one week before their scheduled appointment.

Brain Injury Vision Symptom Survey (BIVSS)
$0.00

Any patients seeking vision therapy due to a brain injury should fill this out and submit it at least one week before their scheduled appointment.

Dizziness Handicap Inventory (DHI)
$0.00

Patients seeking vision therapy who also suffer from dizziness should fill this out at least one week before their scheduled appointment.

School Age Child History Form
$0.00

For any patients, who are in school (K-12), who are seeking vision therapy. Please return this completed form at least one week before their scheduled appointment with Dr. Johnson.

Head Trauma History Form
$0.00

For any patients, suffering from head trauma, who are seeking vision therapy. Please return this completed form at least one week before their scheduled appointment with Dr. Johnson.

Young Child History Form
$0.00

For any patients, aged 0-4, who are seeking vision therapy. Please return this completed form at least one week before their scheduled appointment with Dr. Johnson.

Adult Sensorimotor History Form
$0.00

For any adult patients who are seeking vision therapy. Please return this completed form at least one week before your scheduled appointment with Dr. Johnson.

Please submit completed forms by mail, fax, or email.

Email:
info@superioreye.com

Person sitting on a beige couch writing in a notebook with a black pen, wearing a black and white striped shirt.

Fax:
906-225-0460
Attn: Grace

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