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!

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*

	Always	Frequently	Occasionally	Never
1. Do you have headaches or face pain?	Always	Frequently	Occasionally	Never
2. Do you have pain in your eyes with eye movement?	Always	Frequently	Occasionally	Never
3. Do you experience neck or shoulder discomfort?	Always	Frequently	Occasionally	Never
4. Do you have dizziness and / or lightheadedness?	Always	Frequently	Occasionally	Never
5. Do you experience dizziness, light-headedness, or nausea while performing close-up activities (i.e. - computer work, reading, writing)?	Always	Frequently	Occasionally	Never
6. Do you experience dizziness, light-headedness, or nausea while performing far-distance activities (i.e. - driving, television, movies)?	Always	Frequently	Occasionally	Never
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?	Always	Frequently	Occasionally	Never
8. Do you feel unsteady with walking, or drift to one side while walking?	Always	Frequently	Occasionally	Never
9. Do you feel overwhelmed or anxious while walking in a large department store (i.e. - Target, Wal-Mart, etc.)?	Always	Frequently	Occasionally	Never
10. Do you feel overwhelmed or anxious when in a crowd?	Always	Frequently	Occasionally	Never
11. Does riding in a car make you feel dizzy or uncomfortable?	Always	Frequently	Occasionally	Never
12. Do you experience anxiety or nervousness because of your dizziness?	Always	Frequently	Occasionally	Never
13. Do you ever find yourself with your head tilted to one side?	Always	Frequently	Occasionally	Never
14. Do you experience poor depth perception or have difficulty estimating distances accurately?	Always	Frequently	Occasionally	Never
15. Do you experience double / overlapping / shadowed vision at far distances?	Always	Frequently	Occasionally	Never
16. Do you experience double / overlapping / shadowed vision at near distances?	Always	Frequently	Occasionally	Never
17. Do you experience glare or have sensitivity to bright lights?	Always	Frequently	Occasionally	Never
18. Do you close or cover one eye with near or far tasks?	Always	Frequently	Occasionally	Never
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)?	Always	Frequently	Occasionally	Never
20. Do you tire easily with close-up tasks (computer work, reading, writing)?	Always	Frequently	Occasionally	Never
21. Do you experience blurred vision with far-distance activities (i.e. - driving, television, movies, chalkboard at school)?	Always	Frequently	Occasionally	Never
22. Do you experience blurred vision with close-up activities (i.e. - computer work, reading, writing)?	Always	Frequently	Occasionally	Never
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)?	Always	Frequently	Occasionally	Never
24. Do you experience words running together with reading?	Always	Frequently	Occasionally	Never
25. Do you experience difficulty with reading or reading comprehension?	Always	Frequently	Occasionally	Never

Level of Discomfort

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)

	1	2	3	4	5	6	7	8	9	10
Dizziness	1	2	3	4	5	6	7	8	9	10
Nausea	1	2	3	4	5	6	7	8	9	10
Anxiety	1	2	3	4	5	6	7	8	9	10
Headache	1	2	3	4	5	6	7	8	9	10
Neckache	1	2	3	4	5	6	7	8	9	10
Unsteady with Walking	1	2	3	4	5	6	7	8	9	10
Sensitivity to Light	1	2	3	4	5	6	7	8	9	10
Reading Difficulty	1	2	3	4	5	6	7	8	9	10

History

Have you ever been diagnosed with:*

	Yes	No
Learning disability (LD)	Yes	No
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

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.

Adult Symptom Questionnaire

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