Patient Forms

At Superior Eye, we offer patient forms online so you can complete them in the convenience of your own home or office. Fax or email us your completed forms or bring them with you to your visit.
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  • If you do not already have AdobeReader® installed on your computer, Click Here to download it now.

  • Download the necessary form(s) and fill in the required information.

  • Fax or email us your completed form(s) or bring them with you to your appointment.

Adult History Form

for ages 18+

Head Trauma History Form

for anyone who has been in a moving vehicle accident, concussions, brain surgeries, strokes

Convergence Insufficiency Symptom Survey (CISS)

for everyone

School Age History

for ages 6-18

Young Child History

for ages 5 and under

Authorization for Release of Medical Information

for everyone

DHI Dizziness Handicap Inventory

for anyone suffering from dizziness

Brain Injury Vision Symptom Survey (BIVSS)

for anyone suffering from a brain injury

The Migraine Disability Assessment Test (MIDAS)

for anyone suffering from migraines

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