Patient Forms

Ocean and sand

General Patient Forms

1.1 Welcome: General Patient History Form [PDF][Online]

1.2 Patient Case History Form [PDF]

Sand and ocean

VT Forms

2.1 Childrens Vision and Learning Questionnaire [PDF]

2.2 Visual Symptoms Checklist [PDF][Online]

2.3 Authorization To Release Medical Info [PDF]

Clear water at the beach

Office Policy | Other

Office Policy (Updated 2020) [PDF][Online]

BVDVH Questionnaire [PDF][Online]

The 5 Minute Cover Test [PDF][Online]

Please contact our office if you have any questions or concerns.

Mahalo!

– Quick Links –

^{About Our Office | Dr. Gushiken
Patient Forms
Contact Info
Blogs & Updates}

– Resources –

^{Visual Symptoms Checklist
Comprehensive Visual Evaluation
Second Opinion
Vision Therapy
Causes for Poor Reading
Dyslexia & VT
Prevention
Dizziness, Headaches, Anxiety?}
^{Double Vision}^{College of Optometrists in Vision Development}

– Contact Us –

^{Address:
2353 South Beretania Street
Room 101
Honolulu, Hawaii 96826
Phone: (808) 941-3811
Fax: (808) 951-4063
Email: drclaygushiken@gmail.com}
^{Hours | Direction}