Child 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: Children – answer these questions together with your Parents. For every question, select 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. Distinguishing similarities and differences in forming letters and/or objects

2. Discriminating between sizes of objects

3. Matching 2-D to 3-D objects

4. Difficulty with reversals in letters or numbers

5. Difficulty writing in a straight line/within the margins

6. Difficulty attending to a word on a printed page due to the inability to block out the surrounding words

7. Sorting and organizing personal work

8. Difficulty copying from the board, etc.

9. Difficulty scanning text to locate specific information

10. Decreased reading speed

11. Difficulty completing a thought

12. Difficulty with “p, q and g” and “a and o”, “b and d”.

13. Slow/Difficulty copying from a text or board

14. Trouble following multi-step instructions

15. Eyes feel tried when reading or doing close work?

16. Skip lines or words when reading or doing near work?

17. Eyes feel uncomfortable when reading or doing close work?

18. Do you get headaches when doing close work? Feel sleepy when reading or doing close work?

19. Trouble remembering what you read?

20. Double vision at distance or near?

21. See the words move, jump, swim, or appear to float when reading?

22. Lose concentration when reading or doing near work?

23. Consider yourself a slow reader?

24. Eyes hurt of feel strained?

25. Feel a “pulling” feeling around your eyes when reading or doing close work?

26. Notice words coming in and out of focus when reading or distance?

27. Loose your place when reading?

28. Eyes feel sore?

29. Re-read the same line when doing near work?

30. Feel like you need to work harder to achieve the

31. Same level of success as your peers?

32. Substitute words when reading?

33. Squint/close your eyes when reading or doing near work?

34. Avoids near tasks?

35. Dry eyes?

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)

Dyslexia

Torticollis

Lazy Eye?

Reading disability?

ADD / ADHD?

Migraines or headache disorder?

Traumatic brain injury or concussion?

Does your child blink their eyes a lot / much more then most children?

Is your child's verbal skills far ahead of their reading skills?

Has your child 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.