Skip to main content

Next to the Chinatown Gate entrance in San Francisco

Call Now! 415-683-6440

Schedule An Appointment

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

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

Patient History Form

Schedule An Appointment

Read Patient Reviews

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.

Click here for a Map & Directions

Find Us Here

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

Search:

Quick Links

Home
Contact Us
Your Eye Health
Disclaimer
HIPAA Privacy Policy

Home
Contact Us
Your Eye Health
Disclaimer
HIPAA Privacy Policy

Are You Looking for

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

Powered by EyeCarePro.com
The materials and articles contained on this website are copyrighted and protected under Title 17 of the United States Code
Sitemap | Email Accessibility | Website Accessibility Policy | Login