Adult Binocular Vision Dysfunction Questionnaire If you think that you might have Binocular Vision Dysfunction, please fill out this Questionnaire and submit to us after completion. We will interpret your responses and contact you regarding the results. Please note: This questionnaire is for those 14 years old or older. If you are 13 years old or younger, please click here. Date Date Format: MM slash DD slash YYYY Name* First Last Date of Birth* Date Format: MM slash DD slash YYYY Email* Phone (Main)*Phone (Alternative - Optional)Location* City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Directions:For each of the following questions, please check the answer that best describes your situation. If you wear glasses or contact lenses, answer the questions assuming that you are wearing them.Always = Every day Frequently = At least 1 time / week Occasionally = Less than 1 time / week Never = Never1. Do you have headaches and / or facial pain?*AlwaysFrequentlyOccasionallyNeverDescribe location of discomfort on face or back of head:Rate your discomfort on a scale from 1-10: 1=extremely mild, 10=extremely severe123456789102. Do you have pain in your eyes with eye movement?*AlwaysFrequentlyOccasionallyNever3. Do you experience neck or shoulder discomfort?*AlwaysFrequentlyOccasionallyNever4. Do you have dizziness and / or lightheadedness?*AlwaysFrequentlyOccasionallyNever5. Do you experience dizziness, light-headedness, or nausea while performing close-up activities (i.e. - computer work, reading, writing)?*AlwaysFrequentlyOccasionallyNever6. Do you experience dizziness, light-headedness, or nausea while performing far-distance activities (i.e. - driving, television, movies)?*AlwaysFrequentlyOccasionallyNever7. Do you experience dizziness, light-headedness, or nausea when bending down and standing back up, or when getting up quickly from a seated position?*AlwaysFrequentlyOccasionallyNever8. Do you feel unsteady with walking, or drift to one side while walking?*AlwaysFrequentlyOccasionallyNever9. Do you feel overwhelmed or anxious while walking in a large department store (i.e. – Target, Costco, Malls)?*AlwaysFrequentlyOccasionallyNever10. Do you feel overwhelmed or anxious when in a crowd?*AlwaysFrequentlyOccasionallyNever11. Does riding in a car make you feel dizzy or uncomfortable?*AlwaysFrequentlyOccasionallyNever12. Do you experience anxiety or nervousness because of your dizziness?*AlwaysFrequentlyOccasionallyNever13. Do you ever find yourself with your head tilted to one side?*AlwaysFrequentlyOccasionallyNever14. Do you experience poor depth perception or have difficulty estimating distances accurately?*AlwaysFrequentlyOccasionallyNever15. Do you experience double/overlapping/shadowed vision at far distances?*AlwaysFrequentlyOccasionallyNever16. Do you experience double/overlapping/shadowed vision at near distances?*AlwaysFrequentlyOccasionallyNever17. Do you experience glare or have sensitivity to bright lights?*AlwaysFrequentlyOccasionallyNever18. Do you close or cover one eye with near or far tasks?*AlwaysFrequentlyOccasionallyNever19. Do you skip lines or lose your place while reading (do you use your finger or a ruler or other guides to maintain your position on the page)?*AlwaysFrequentlyOccasionallyNever20. Do you tire easily with close-up tasks (computer work, reading, writing)?*AlwaysFrequentlyOccasionallyNever21. Do you experience blurred vision with far-distance activities (i.e.-driving, television, movies, chalkboard at school)?*AlwaysFrequentlyOccasionallyNever22. Do you experience blurred vision with close-up activities (i.e.- computer, reading, writing)?*AlwaysFrequentlyOccasionallyNever23. Do you blink to "clear up" distant objects after working at a desk or working with close-up activities (i.e.- computer work, reading, writing)?*AlwaysFrequentlyOccasionallyNever24. Do you experience words running together with reading?*AlwaysFrequentlyOccasionallyNever25. Do you experience difficulty with reading or reading comprehension?*AlwaysFrequentlyOccasionallyNeverTraumatic brain injury or concussion?*YesNoHistory of ear infections?*YesNoHave you ever been diagnosed with a lazy eye? Yes No Reading disability?*YesNoHave you ever had an eye operation?*YesNoOn an average day, how much are you bothered by the 8 symptoms listed below? Rate each symptom from 0 to 10, where 10 is the worst it could be, and where 0 means you have none of that symptom.Dizziness =012345678910Nausea =012345678910Anxiety =012345678910Headache =012345678910Neckache =012345678910Unsteady with walking =012345678910Sensitivity to light =012345678910Reading difficulty =012345678910Please record any additional symptoms you may be experiencing or specific concerns that you have about your eyes / vision:Tell us how you found us*Internet SearchReferred by a friendReferred by a professionalFound us in a forum, blog or social mediaPlease help us help others by using this box to be very specific about how you found us:*Examples include: •If you found us by Internet search, what key words did you use? •If you were referred, who specifically referred you? •If you found out about us on a blog or forum or social media site, specifically which one was it? •Other: Please explain | Heard about us - where?