Personal Information

Patient Name(Required)

First Last

Date of Birth(Required)

MM slash DD slash YYYY

Sex(Required)

Male

Female

Other

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Do you identify as LGBTQ+?

Yes

Email(Required)

Enter Email Confirm Email

How did you learn about our office?

Have you been formally diagnosed with visual snow syndrome?

When did your symptoms begin, and what was the context of the symptoms’ onset?

Review of Vision Symptoms

Symptoms:

For each symptom listed below, please select the box that describes the frequency/severity to which you experience this symptom.

0 = Never

1 = Rarely/Mild

2 = Sometimes/Moderate

3= Frequently/Marked

4 = Always/Severe

Static in Vision(Required)

	Never	Rarely/Mild	Sometimes/Moderate	Frequently/Marked	Always/Severe
Static in vision – Black and white
Static in vision - Colored

If you have colored static vision, please specify which colors:

Visual Symptoms(Required)

	Never	Rarely/Mild	Sometimes/Moderate	Frequently/Marked	Always/Severe
Flashing lights in vision (photopsia)
Impaired night vision (nyctalopia)
Perceiving trails behind moving objects (palinopsia)
Perceiving an image after looking away from it or closing your eyes (after-images)
Sparkling white dots in vision (blue-field entoptic phenomenon)
Halos, streaks, or starbursts around lights Increased floaters or awareness of the eye area and its contents (enhanced entoptic phenomena)
Shadowing, ghosting, or pseudo-double vision Impaired contrast sensitivity
True double vision (diplopia)

Light sensitivity (photophobia)(Required)

	Never	Rarely/Mild	Sometimes/Moderate	Frequently/Marked	Always/Severe
To sunlight
To fluorescent lights
To electronic screens
To specific colors of light*
Other*

*If you are sensitive to specific colors of light or some other form, please specify:

Symptoms Related to Perception(Required)

	Never	Rarely/Mild	Sometimes/Moderate	Frequently/Marked	Always/Severe
Perception of motion where there is none (oscillopsia)
Sensitivity to high-contrast stimuli such as stripes and patterns (pattern glare)
Inability to make mental images or visualize (aphantasia)
Face blindness (prosopagnosia)
Perception of waves or ripples in vision
Vision going in and out of focus/fluctuating
Other vision disturbances*

*If you experience other vision disturbances, please specify:

Visual Symptoms Pertaining to Reading

Can you read comfortably?

If so, for how long?

Is it harder to read on a screen or on paper, or is it equal?

For each symptom, choose the frequency/extent to which you experience this symptom while reading.(Required)

	Never	Rarely/Mild	Sometimes/Moderate	Frequently/Marked	Always/Severe
Headaches
Blurry or fluctuating vision while reading
Double vision
Dizziness
Nausea
Eyestrain
Fatigue while reading
Skipping words or lines of text, misreading words, adding words, losing place
Words appear to shake, vibrate, or otherwise move
Other*

*If you experience other symptoms, please specify:

General Systemic Symptoms

For each symptom, choose the frequency/extent to which you experience this symptom.(Required)

	Never	Rarely/Mild	Sometimes/Moderate	Frequently/Marked	Always/Severe
Headaches
Generalized fatigue
Cognitive disturbances or “brain fog”
Migraine – With aura
Migraine – Without aura
Ringing in ears (tinnitus)
Sound sensitivity (hyperacusis)
Synesthesia (stimulating one sense stimulates another, ie seeing sounds or hearing colors)
Tingling or “pins and needles” sensations (paresthesia)
Other*

Pain – Please specify all that apply:(Required)

	Never	Rarely/Mild	Sometimes/Moderate	Frequently/Marked	Always/Severe
Back
Head
Jaw
Joints
Neck
Other*

Vestibular System

Vestibular Symptoms(Required)

	Never	Rarely/Mild	Sometimes/Moderate	Frequently/Marked	Always/Severe
Dizziness/Vertigo
Nausea
Loss of balance
Perception of the ground as moving, slanted, or uneven

Carsickness(Required)

	Never	Rarely/Mild	Sometimes/Moderate	Frequently/Marked	Always/Severe
As driver
As passenger

Please specify after how long:

Do you experience feelings of overstimulation, uneasiness, loss of equilibrium, and/or other types of discomfort in the following environments?(Required)

Airports

Classrooms

Crowds

Grocery stores

Hallways

Malls

Restaurants

Other (please specify)

For Other, please specify:

Psychiatric Symptoms

Do you personally experience any of the following symptoms?(Required)

	Never	Rarely/Mild	Sometimes/Moderate	Frequently/Marked	Always/Severe
Anxiety
Depression
Insomnia
Feeling of disconnection from reality/from your body, or like you are living in a dream (depersonalization/derealization)
Suicidal ideation

Hallucinations(Required)

	Never	Rarely/Mild	Sometimes/Moderate	Frequently/Marked	Always/Severe
Auditory (hearing)
Olfactory (smell)
Tactile (touch)
Visual

Activities of Daily Living

Employment status(Required)

Working full-time

Working part-time

On disability

Part-time student

Full-time student

Unemployed

Retired

Do you feel your condition interferes with any activities related to work or study? If so, how so?(Required)

Do you receive any accommodations in your work environment?(Required)

Do you receive any accommodations (IEP or 504 plan)? If so, what accommodations?(Required)

Have you been diagnosed as gifted/high IQ, or have you been diagnosed with a learning disability? Please specify.(Required)

Are you restricted in your level of physical activity?(Required)

Other Therapies/Treatments

What other types of therapies or treatments have you had?

Please include Name, City of provider and/or practice, and Type of specialty.

What other professionals are involved in your care?

Please include Name, City of provider and/or practice, and Type of specialty.

Associated Conditions

Do you have a history of any of the following conditions?

Anxiety or panic disorders

Arthritis

Autism spectrum disorder

Attention deficit hyperactivity disorder

Celiac disease

Chiari malformation

Chronic Lyme disease

Concussion/Traumatic Brain Injury (TBI) – please specify approximate dates of known concussions

Depression

Dysautonomia/POTS

Hashimoto’s disease

Learning disability (please specify)

Long COVID-19

Lupus

Mold toxicity

Parasitic infections

Pineal cyst

Pituitary cyst

Post-traumatic stress disorder

Rathke cleft cyst

Substance abuse (please specify which prescription or non-prescription drug(s))

TMJ dysfunction

Type 1 diabetes

Do you have other neurological, psychiatric, or autoimmune conditions? Please specify.

Do you have any family history of any of these conditions or of visual snow syndrome?

Medications/Supplements

Please list name and dosage of all current medications and supplements

Have you ever in the past used any of the following substances? If so, please specify.

SSRI or SNRI antidepressant medications
- Examples: Zoloft, Prozac
Stimulant medications
- Examples: ADHD medications like Adderall, Ritalin
Non-prescription stimulant drugs
- Examples: cocaine, methamphetamine
Cannabis in any form
- Methods: smoking, edibles, vaping, others
Hallucinogenic substances

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