Child/Student Symptom Questionnaire

Binocular Vision Dysfunction 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: 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*

	Always	Frequently	Occasionally	Never
1. Distinguishing similarities and differences in forming letters and/or objects	Always	Frequently	Occasionally	Never
2. Discriminating between sizes of objects	Always	Frequently	Occasionally	Never
3. Matching 2-D to 3-D objects	Always	Frequently	Occasionally	Never
4. Difficulty with reversals in letters or numbers	Always	Frequently	Occasionally	Never
5. Difficulty writing in a straight line/within the margins	Always	Frequently	Occasionally	Never
6. Difficulty attending to a word on a printed page due to the inability to block out the surrounding words	Always	Frequently	Occasionally	Never
7. Sorting and organizing personal work	Always	Frequently	Occasionally	Never
8. Difficulty copying from the board, etc.	Always	Frequently	Occasionally	Never
9. Difficulty scanning text to locate specific information	Always	Frequently	Occasionally	Never
10. Decreased reading speed	Always	Frequently	Occasionally	Never
11. Difficulty completing a thought	Always	Frequently	Occasionally	Never
12. Difficulty with “p, q and g” and “a and o”, “b and d”.	Always	Frequently	Occasionally	Never
13. Slow/Difficulty copying from a text or board	Always	Frequently	Occasionally	Never
14. Trouble following multi-step instructions	Always	Frequently	Occasionally	Never
15. Eyes feel tried when reading or doing close work?	Always	Frequently	Occasionally	Never
16. Skip lines or words when reading or doing near work?	Always	Frequently	Occasionally	Never
17. Eyes feel uncomfortable when reading or doing close work?	Always	Frequently	Occasionally	Never
18. Do you get headaches when doing close work? Feel sleepy when reading or doing close work?	Always	Frequently	Occasionally	Never
19. Trouble remembering what you read?	Always	Frequently	Occasionally	Never
20. Double vision at distance or near?	Always	Frequently	Occasionally	Never
21. See the words move, jump, swim, or appear to float when reading?	Always	Frequently	Occasionally	Never
22. Lose concentration when reading or doing near work?	Always	Frequently	Occasionally	Never
23. Consider yourself a slow reader?	Always	Frequently	Occasionally	Never
24. Eyes hurt of feel strained?	Always	Frequently	Occasionally	Never
25. Feel a “pulling” feeling around your eyes when reading or doing close work?	Always	Frequently	Occasionally	Never
26. Notice words coming in and out of focus when reading or distance?	Always	Frequently	Occasionally	Never
27. Loose your place when reading?	Always	Frequently	Occasionally	Never
28. Eyes feel sore?	Always	Frequently	Occasionally	Never
29. Re-read the same line when doing near work?	Always	Frequently	Occasionally	Never
30. Feel like you need to work harder to achieve the	Always	Frequently	Occasionally	Never
31. Lsame level of success as your peers?	Always	Frequently	Occasionally	Never
32. Substitute words when reading?	Always	Frequently	Occasionally	Never
33. Squint/close your eyes when reading or doing near work?	Always	Frequently	Occasionally	Never
34. Avoids near tasks?	Always	Frequently	Occasionally	Never
35. Dry eyes?	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	1	2	3	4	5	6	7	8	9	10
Sensitivity	1	2	3	4	5	6	7	8	9	10
Reading	1	2	3	4	5	6	7	8	9	10

History

Have you ever been diagnosed with:*

	Yes	No
Learning disability (LD)	Yes	No
Dyslexia	Yes	No
Torticollis	Yes	No
Lazy	Yes	No
Reading disability?	Yes	No
ADD / ADHD?	Yes	No
Migraines or headache disorder?	Yes	No
Traumatic brain injury or concussion?	Yes	No
Does your child blink their eyes a lot / much more then most children?	Yes	No
Are your child's verbal skills far ahead of their reading skills?	Yes	No
Has your child 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 your doctor. The office will call you after the results have been reviewed

Binocular Vision Dysfunction Questionnaire

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