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?* Never Occasionally Frequently Always
2. Do you have pain in your eyes with eye movement?* Never Occasionally Frequently Always
3. Do you experience neck or shoulder discomfort?* Never Occasionally Frequently Always
4. Do you have dizziness and / or lightheadedness?* Never Occasionally Frequently Always
5. Do you experience dizziness, light-headedness, or nausea while performing close-up activities (i.e. - computer work, reading, writing)?* Never Occasionally Frequently Always
6. Do you experience dizziness, light-headedness, or nausea while performing far-distance activities (i.e. - driving, television, movies)?* Never Occasionally Frequently Always
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?* Never Occasionally Frequently Always
8. Do you feel unsteady with walking, or drift to one side while walking? Never Occasionally Frequently Always
9. Do you feel overwhelmed or anxious while walking in a large department store (i.e. Target, Wal-Mart, Meijer)? Never Occasionally Frequently Always
10. Do you feel overwhelmed or anxious when in a crowd? Never Occasionally Frequently Always
11. Does riding in a car make you feel dizzy or uncomfortable?* Never Occasionally Frequently Always
12. Do you experience anxiety or nervousness because of your dizziness?* Never Occasionally Frequently Always
13. Do you ever find yourself with your head tilted to one side?* Never Occasionally Frequently Always
14. Do you experience poor depth perception or have difficulty estimating distances accurately?* Never Occasionally Frequently Always
15. Do you experience double / overlapping / shadowed vision at far distances?* Never Occasionally Frequently Always
16. Do you experience double / overlapping / shadowed vision at near distances?* Never Occasionally Frequently Always
17. Do you experience glare or have sensitivity to bright lights?* Never Occasionally Frequently Always
18. Do you close or cover one eye with near or far tasks?* Never Occasionally Frequently Always
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)?* Never Occasionally Frequently Always
20. Do you tire easily with close-up tasks (computer work, reading, writing)?* Never Occasionally Frequently Always
21. Do you experience blurred vision with far-distance activities (i.e. - driving, television, movies, chalkboard at school)?* Never Occasionally Frequently Always
22. Do you experience blurred vision with close-up activities (i.e. - computer work, reading, writing)?* Never Occasionally Frequently Always
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)?* Never Occasionally Frequently Always
24. Do you experience words running together with reading?* Never Occasionally Frequently Always
25. Do you experience difficulty with reading or reading comprehension?* Never Occasionally Frequently Always
Have you ever been diagnosed with:
Traumatic brain injury or concussion (TBI)?* Yes No
Reading disability?* Yes No
Lazy Eye?* Yes No
Have you 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* 1/10 2/10 3/10 4/10 5/10 6/10 7/10 8/10 9/10 10/10
Nausea* 1/10 2/10 3/10 4/10 5/10 6/10 7/10 8/10 9/10 10/10
Anxiety* 1/10 2/10 3/10 4/10 5/10 6/10 7/10 8/10 9/10 10/10
Headache* 1/10 2/10 3/10 4/10 5/10 6/10 7/10 8/10 9/10 10/10
Neckache* 1/10 2/10 3/10 4/10 5/10 6/10 7/10 8/10 9/10 10/10
Unsteady with walking* 1/10 2/10 3/10 4/10 5/10 6/10 7/10 8/10 9/10 10/10
Sensitivity to light* 1/10 2/10 3/10 4/10 5/10 6/10 7/10 8/10 9/10 10/10
Difficulty Reading* 1/10 2/10 3/10 4/10 5/10 6/10 7/10 8/10 9/10 10/10
Comment Section: If you want to tell us more about you symptoms, or if you have specific questions, record them here: