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:

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BVD Questionnaire – Adult