Name: Heights Eye Center
Address: 227 1/2 Boulevard, Hasbrouck Heights, NJ, 07604, US
Telephone: 201-288-1109
Price range: $000 - $300

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
MM slash DD slash YYYY
Name*
First Last
Date of Birth*
MM slash DD slash YYYY
Email*
Phone (Main)*
Phone (Alternative - Optional)
Location*
City State
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
1. Do you have headaches and / or facial pain?*
- Always
- Frequently
- Occasionally
- Never
2. Do your eyes hurt and/or does it hurt to move your eyes?*
- Always
- Frequently
- Occasionally
- Never
3. Do you have neck pain or a stiff neck or upper back pain?*
- Always
- Frequently
- Occasionally
- Never
4. Do you have stomach aches or nausea?*
- Always
- Frequently
- Occasionally
- Never
5. Do you get car sickness or motion sickness?*
- Always
- Frequently
- Occasionally
- Never
6. Did you get sick in the car seat when you were a small child?*
- Always
- Frequently
- Occasionally
- Never
7. Do you get sick to your stomach or nauseous on swings or circular rides?*
- Always
- Frequently
- Occasionally
- Never
8. Does riding in the car give you headaches or stomach aches?*
- Always
- Frequently
- Occasionally
- Never
9. Do you have trouble reading in the car?*
- Always
- Frequently
- Occasionally
- Never
10. Do you feel clumsy or klutzy or uncoordinated?*
- Always
- Frequently
- Occasionally
- Never
11. When you are walking, do you bump into people or furniture or door frames?*
- Always
- Frequently
- Occasionally
- Never
12. Do you feel funny or dizzy when you bend over and stand back up quickly?*
- Always
- Frequently
- Occasionally
- Never
13. Are you anxious or nervous?*
- Always
- Frequently
- Occasionally
- Never
14. In grocery stores or malls, do you stay close (cling) to your Mom or Dad? (Do you feel uncomfortable in grocery stores or malls?)*
- Always
- Frequently
- Occasionally
- Never
15. Do you tend to play alone or with just a few other kids? (Do you tend to play apart from the main group of kids?)*
- Always
- Frequently
- Occasionally
- Never
16. Is reading hard for you or are you a slow reader?*
- Always
- Frequently
- Occasionally
- Never
17. Do you have to read the same thing a couple of times to really understand it?*
- Always
- Frequently
- Occasionally
- Never
18. Do you use your finger or a ruler or a piece of paper to help you keep your place when you are reading?*
- Always
- Frequently
- Occasionally
- Never
19. Do you skip lines or lose your place when you are reading?*
- Always
- Frequently
- Occasionally
- Never
20. When you read, does it look like the letters are moving OR does it seem like words are bumping into each other?*
- Always
- Frequently
- Occasionally
- Never
21. Do bright lights hurt your eyes?*
- Always
- Frequently
- Occasionally
- Never
22. Do you close or cover one eye to make it easier to see?*
- Always
- Frequently
- Occasionally
- Never
23. Do you have trouble catching baseballs or footballs or Frisbees?*
- Always
- Frequently
- Occasionally
- Never
24. Do you ever see two of everything (double vision)?*
- Always
- Frequently
- Occasionally
- Never
25. Is it hard for you to watch 3-D movies?*
- Always
- Frequently
- Occasionally
- Never
26. When reading or working on the computer, do your eyes feel tired or does your vision get blurry?*
- Always
- Frequently
- Occasionally
- Never
27. When looking at the blackboard at school, do your eyes feel tired or does your vision get blurry?*
- Always
- Frequently
- Occasionally
- Never
Mom / Dad: Has your child ever been diagnosed with:
Learning disability (LD)?*
- Yes
- No
Dyslexia?*
- Yes
- No
Torticollis?*
- Yes
- No
Lazy eye?*
- Yes
- No
History of ear infections?*
- Yes
- No
Reading disability?*
- Yes
- No
ADD / ADHD?*
- Yes
- No
Migraines or headache disorder?*
- Yes
- No
Traumatic brain injury or concussion?*
- Yes
- No
Does your child blink their eyes a lot / much more then most children?*
- Yes
- No
Are your child’s verbal skills far ahead of their reading skills?*
- Yes
- No
Has your child 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 =
- 0
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10
Nausea =
- 0
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10
Anxiety =
- 0
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10
Headache =
- 0
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10
Neckache =
- 0
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10
Unsteady with walking =
- 0
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10
Sensitivity to light =
- 0
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10
Reading difficulty =
- 0
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10
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*
- Internet Search
- Referred by a friend
- Referred by a professional
- Found us in a forum, blog or social media
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?

Directions:

Heights Eye Center