fbpx Skip to main content

BVD Questionnaire – Adult

This is the Adult Binocular Vision Dysfunction Questionnaire for those 14 years old or older.

If you are 13 years old or younger, please click here.

If you think that you might have Binocular Vision Dysfunction, please fill out this Questionnaire and send it to us after it is completed. We will interpret your responses and contact you regarding the results.

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

    First and Last Name*

    Age*

    Daytime Phone Number*

    State*

    Email*

    Directions: For each of the following questions, please select the answer on the drop-down menu 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.

    1. Do you have headaches and / or facial 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, Meijer)?

    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?*

    Have you ever been diagnosed with:

    Traumatic brain injury or concussion (TBI)?*

    Reading disability?*

    Lazy Eye?*

    Have you ever had an eye operation?*

    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*

    Difficulty Reading*

    Comment Section: If you want to tell us more about you symptoms, or if you have specific questions, record them here:

    References: How did you hear about us?:

    What Our Patients Are Saying

    Dr. Sonneberg and her staff are truly outstanding. She is a most experienced, capable and understanding optometrist. My eye exam for prism glasses was extremely thorough and her assistant Michelle picked out frames for me that were best suited for my needs. It was a great experience for me and it will be for you too. I highly recommend her.

    Susan S.

    This was such an amazing experience. They made me feel comfortable and made sure I knew everything that was going on. Dr. Sonneberg was absolutely amazing and her staff were so great as well. I would highly recommend going to them with any eye issues you may be experiencing or related symptoms. She definitely changed my life.

    McKenzie C.

    Exceptional experience from start to finish. All staff is extremely friendly and knowledgeable. Dr. Sonneberg is patient and kind. I am forever grateful for this team for helping me discover a diagnosis and treatment for my condition that has had me very sick for over 2 months. Highly recommend.

    Sarah C.

    I can’t even put into words how validated & happy I feel today after visiting Dr. Sonneberg’s office. From the front staff, to the doctor, to the location everything was perfect. She makes you feel so comfortable and truly wants to get to the root cause of your issues and find you answers, no matter what. She is very thorough and honest to get you to the best you can be. I am so excited to finally be diagnosed with converge insufficiency & vertical heterophoria and am on my path to recovery. If you are having any uncomfortable vision issues, neck or shoulder pain, a head tilt, dizziness or anxiety you need to see her immediately. It’ll change your life I promise you that!

    Sierra B.

    Dr. Sonneberg does a thorough examination. She is never satisfied until the refraction she prescribes is as good as it can be. She is patient and persistent in her efforts to help her patients.

    Denise J.

    My experience here was very positive. The staff is all very friendly and accommodating. Dr. Sonneberg's exam was thorough. This was my first visit and she took the time to learn in detail about my vision history and specific vision problem. She made an excellent recommendation as far as further treatment I may require. I felt no pressure to spend any more than I'd planned and no service or product was "pushed" on me as a prior writer complained. I have no problem recommending this office to anyone.

    UPDATE: It's been 5 years since I wrote this first visit review. Nothing I said then needs to be changed. I was there this morning and my visit could not have been pleasanter. I'd give 10 stars if I could.

    Beth B.

    My son and I are new patients of Dr. Sonnenberg. After my initial visit with Dr. Sonnenberg, I had an emergency; I called her. She told me to come right over! She is very caring, compassionate, considerate, and warm. She took care of me right away. She is an amazing doctor! I can't imagine going to anyone else. Her office staff is friendly, courteous and knows their stuff! The office is relaxing; no rushing around! I will be a patient of Dr. Sonnenberg's forever! If you are looking for a good optometrist, she is the one to see. I travel from Coral Springs to see her. Thank you Dr. Sonnenberg and staff!

    Penny D.

    Love this office!! Dr Sonneberg is so patient and friendly, and has really made a difference in my son's vision!! She is very thorough too! Her office staff is always smiling, having cute interactions with my kids, and very on the ball and organized. Best eye doctor we've ever been to!

    Chani R.

    Dr. Sonneberg and her team are incredible! This was hands down the best experience I’ve ever had buying glasses and having my eyes checked. Deena and Dr. Sonneberg have amazing expertise in selecting frames and helped me pick ones that I never would have chosen, but are beyond perfect. And my eye exam with Dr. Sonneberg was very efficient and easy, and she took time to answer all of my questions and make sure I was comfortable with my contact lenses and glasses. I can't recommend Dr. Sonneberg’s office highly enough— a perfect experience.

    Hadas A.

    I have been coming here for years and always have a great experience with Dr Sonneberg and the staff! They are very friendly and welcoming! Their attention to detail and the quality you get with your exam and fitting of glasses/contacts is the reason I keep coming back! Highly recommend!

    Brett S.

    BVD Questionnaire – Adult

    This is the Adult Binocular Vision Dysfunction Questionnaire for those 14 years old or older.

    If you are 13 years old or younger, please click here.

    If you think that you might have Binocular Vision Dysfunction, please fill out this Questionnaire and send it to us after it is completed. We will interpret your responses and contact you regarding the results.

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

      First and Last Name*

      Age*

      Daytime Phone Number*

      State*

      Email*

      Directions: For each of the following questions, please select the answer on the drop-down menu 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.

      1. Do you have headaches and / or facial 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, Meijer)?

      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?*

      Have you ever been diagnosed with:

      Traumatic brain injury or concussion (TBI)?*

      Reading disability?*

      Lazy Eye?*

      Have you ever had an eye operation?*

      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*

      Difficulty Reading*

      Comment Section: If you want to tell us more about you symptoms, or if you have specific questions, record them here:

      References: How did you hear about us?: