Adult Symptom Questionnaire

If you think you have Binocular Vision Dysfunction (BVD), this questionnaire will take you just a few minutes to complete! See if Vision Therapy/Vision Rehabilitation is the right treatment plan for you!
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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. Please answer every question.

  • Never = Never

  • Occasionally = Less than 1 time / week

  • Frequently = At least 1 time / week

  • Always = Everyday​​​​​​​


    (*) indicates a required field.

Symptoms*

1. Do you have headaches or face pain?

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

3. Do you experience neck or shoulder discomfort?

4. Do you have dizziness and / or lightheadedness?

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

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

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?

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

9. Do you feel overwhelmed or anxious while walking in a large department store (i.e. - Target, Wal-Mart, etc.)?

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

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

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

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

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

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

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

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

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

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)?

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

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

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

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)?

24. Do you experience words running together with reading?

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

Discomfort*

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

History

Have you ever been diagnosed with:*

Learning disability (LD)

Traumatic brain injury or concussion (TBI)?

Reading disability?

Lazy Eye?

Have you ever had an eye operation?

Tell Us Your Story

If you would like to tell us more about your symptoms, please write about them here. We will combine this information with the responses you gave in the Questionnaire to provide you with a more detailed interpretation of the results.

Fill out your contact information for the results of the survey to be sent to the doctor.
The office will call you after the results have been reviewed.