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Pediatric Binocular Vision Dysfunction Questionnaire

If you think that your child 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 13 years old or younger.

If your child is 14 years old or older, please click here.

  • This questionnaire is used by our practice for evaluation purposes. The results will be sent to our office, and we will contact you shortly after to review them with you. This questionnaire is for ages 14 and under.
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Directions:

    Children - answer these questions together with your Parents. For every question, check the answer that best describes your situation. If you wear glasses or contact lenses, answer the questions assuming that you are wearing them. Please answer every question.
  • Always = Every day
    Frequently = At least 1 time / week
    Occasionally = Less than 1 time / week
    Never = Never
  • Mom / Dad: Has your child ever been diagnosed with:

  • 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?