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

Name*

First Last

Date of Birth*

Email*

Phone (Main)*

Phone (Alternative - Optional)

Location*

City 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 = Never

1. Do you have headaches and / or facial pain?*

Always
Frequently
Occasionally
Never

Describe location of discomfort on face or back of head:

Rate your discomfort on a scale from 1-10: 1=extremely mild, 10=extremely severe

2. Do you have pain in your eyes with eye movement?*

Always
Frequently
Occasionally
Never

3. Do you experience neck or shoulder discomfort?*

Always
Frequently
Occasionally
Never

4. Do you have dizziness and / or lightheadedness?*

Always
Frequently
Occasionally
Never

5. Do you experience dizziness, light-headedness, or nausea while performing close-up activities (i.e. - computer work, reading, writing)?*

Always
Frequently
Occasionally
Never

6. Do you experience dizziness, light-headedness, or nausea while performing far-distance activities (i.e. - driving, television, movies)?*

Always
Frequently
Occasionally
Never

7. Do you experience dizziness, light-headedness, or nausea when bending down and standing back up, or when getting up quickly from a seated position?*

Always
Frequently
Occasionally
Never

8. Do you feel unsteady with walking, or drift to one side while walking?*

Always
Frequently
Occasionally
Never

9. Do you feel overwhelmed or anxious while walking in a large department store (i.e. – Target, Costco, Malls)?*

Always
Frequently
Occasionally
Never

10. Do you feel overwhelmed or anxious when in a crowd?*

Always
Frequently
Occasionally
Never

11. Does riding in a car make you feel dizzy or uncomfortable?*

Always
Frequently
Occasionally
Never

12. Do you experience anxiety or nervousness because of your dizziness?*

Always
Frequently
Occasionally
Never

13. Do you ever find yourself with your head tilted to one side?*

Always
Frequently
Occasionally
Never

14. Do you experience poor depth perception or have difficulty estimating distances accurately?*

Always
Frequently
Occasionally
Never

15. Do you experience double/overlapping/shadowed vision at far distances?*

Always
Frequently
Occasionally
Never

16. Do you experience double/overlapping/shadowed vision at near distances?*

Always
Frequently
Occasionally
Never

17. Do you experience glare or have sensitivity to bright lights?*

Always
Frequently
Occasionally
Never

18. Do you close or cover one eye with near or far tasks?*

Always
Frequently
Occasionally
Never

19. 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)?*

Always
Frequently
Occasionally
Never

20. Do you tire easily with close-up tasks (computer work, reading, writing)?*

Always
Frequently
Occasionally
Never

21. Do you experience blurred vision with far-distance activities (i.e.-driving, television, movies, chalkboard at school)?*

Always
Frequently
Occasionally
Never

22. Do you experience blurred vision with close-up activities (i.e.- computer, reading, writing)?*

Always
Frequently
Occasionally
Never

23. 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)?*

Always
Frequently
Occasionally
Never

24. Do you experience words running together with reading?*

Always
Frequently
Occasionally
Never

25. Do you experience difficulty with reading or reading comprehension?*

Always
Frequently
Occasionally
Never

Traumatic brain injury or concussion?*

Yes
No

History of ear infections?*

Yes
No

Have you ever been diagnosed with a lazy eye?

Yes
No

Reading disability?*

Yes
No

Have you ever had an eye operation?*

Yes
No

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.

Dizziness =

Nausea =

Anxiety =

Headache =

Neckache =

Unsteady with walking =

Sensitivity to light =

Reading difficulty =

Please record any additional symptoms you may be experiencing or specific concerns that you have about your eyes / vision:

Tell us how you found us*

Please 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?

Adult Binocular Vision Dysfunction Questionnaire

Directions:

Heights Eye Center