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Home » Contact Us » Patient Forms » Adult Binocular Vision Dysfunction Questionnaire

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.

  • MM slash DD slash YYYY
  • MM slash DD slash YYYY

  • 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 = Never

  • On 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.
  • 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?