Binocular Vision Dysfunction Questionnaire for Children

Introduction
If you think that you might have Binocular Vision Dysfunction, please fill out this Questionnaire. 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.

Please Note: We will not sell or otherwise use information on this form except in addressing your inquiry. Please see our Privacy Policy.
Contact Information
Name*
First Last
Your Age*
Best Phone Number*
Alternate Phone Number
Email*
State and Country*
State Country
Best Day to be Contacted
Best Time to be Contacted
Next Best Day to be Contacted
Next Best Time to be Contacted

26. When reading or working on the computer, do your eyes feel tired or does your vision get blurry?*
- Never
- Occasionally
- Frequently
- Always
27. When looking at the blackboard at school, do your eyes feel tired or does your vision get blurry?*
- Never
- Occasionally
- Frequently
- Always

How frequent do you experience:
On an average day, how much are you bothered by the 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*

Have more to share?
Comment Section
If you want to tell us more about your symptoms, or if you have specific questions, record them here.
Tell us how you found us.*
- Internet Search
- Referred by a Friend
- Referred by a Professional
- Forum, Blog or Social Media
Please explain*
Internet Search: Please include the keywords you used
Referred by a Friend or Professional: Please let us know who.
Forum, Blog or Social Media: Which one?
Other: Please explain | Heard about us - where?
Please Note: We will not sell or otherwise use information on this form except in addressing your inquiry. Please see our Privacy Policy.
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BVD Score
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SSI Score

Child Binocular Vision Dysfunction Questionnaire