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Meet Our Eye Doctors
- Dr. Vincent Penza
- Dr. Katherine Morioka
Eye Care Services
Eyewear & Contacts
Binocular Vision Dysfunction (BVD)
Hours & Directions
Insurance

Home » SSCD SYMPTOM QUESTIONNAIRE

SSCD SYMPTOM QUESTIONNAIRE

Name
First Last
Date
Date Format: MM slash DD slash YYYY
1. Do you experience dizziness or notice an increase in dizziness when speaking in a loud voice or in response to loud noises?
- Yes
- No
2. Do people mention to you that your speaking voice is soft even though it seems loud to you?
- Yes
- No
3. Have you ever yelled and felt like you were going to pass out?
- Yes
- No
4. Do your eyes hurt to move up and down, side to side, or feel like they are scraping or dragging while moving?
- Yes
- No
5. Have people commented that your eyes twitch or do you feel them twitching?
- Yes
- No
6. Can you hear your own heart beat inside your head when lying down on one side, when having a severe dizzy episode, or during physical exertion?
- Yes
- No
7. Do you have a feeling of fullness in one or both ears?
- Yes
- No
8. When you hum or sing, can you see things move or does it make you dizzy?
- Yes
- No
9. When you cough or sneeze, do you feel like things are moving or does it make you dizzy?
- Yes
- No
10. Do you get dizzy when lifting heavy objects or when exerting yourself through exercise?
- Yes
- No
11. Do you sense that objects on the horizon seem to “bounce”, in your field of vision, while walking/running?
- Yes
- No
12. Have you ever had the feeling that fluid was leaking out of one of your ears, yet there wasn’t any fluid there?
- Yes
- No
13. Have you ever felt dizzy when there was a storm front passing through and there was a noticeable change in barometric pressure?
- Yes
- No
14. Do you feel a constant sway in your body?
- Yes
- No
15. Do you have ringing in one or both ears?
- Yes
- No
16. Do you experience dizziness or fullness when lying flat?
- Yes
- No

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City Optometry

530 Bush St #101
San Francisco, CA 94108

Monday: 9:00 AM - 5:30 PM
Tuesday: 9:00 AM - 5:30 PM
Wednesday: 9:00 AM - 5:30 PM
Thursday: 9:00 AM - 5:30 PM
Friday: 9:30 AM - 5:30 PM
Saturday: Closed
Sunday: Closed

NOTE: On Saturdays, the doctor is available from 9:00 am - 2:30 pm. The Optical Boutique is open from 9:00 am - 4:00 pm.

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City Optometry - Located at 530 Bush St #101, San Francisco, CA, 94108. Phone: 415-291-8560 . https://www.city-optometry.com

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Meet Our Eye Doctors
Eye Care Services
Eyewear & Contacts
Binocular Vision Dysfunction (BVD)
Hours & Directions
Insurance

Meet Our Eye Doctors
Eye Care Services
Eyewear & Contacts
Binocular Vision Dysfunction (BVD)
Hours & Directions
Insurance

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