Skip to main content

Our COVID protocols | Telemedicine / Teletherapy

Located on Route 9 North in Old Bridge, NJ
732-393-8636
Patient Forms
Request Appointment
Open Menu
Menu
Close Menu
Moshe-Slides-v3-6
Moshe-Slides-v3-2
Home » Adult Binocular Vision Dysfunction Questionnaire

Adult Binocular Vision Dysfunction Questionnaire

If you think that you might have Binocular Vision Dysfunction, please fill out this Questionnaire and submit to us after completion. We will interpret your responses and contact you regarding the results.

  • Please note: This questionnaire is for those 14 years old or older.
    If you are 13 years old or younger, please click here.

    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.
    (*) indicates a required field.

    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

  • AlwaysFrequentlyOccasionallyNever
    1. Do you have headaches and / or facial pain?
    2. Do you have pain in your eyes with eye movement?
    3. Do you experience neck or shoulder discomfort?
    4. Do you have dizziness and / or lightheadedness?
    5. Do you experience dizziness, light-headedness, or nausea while performing close-up activities (i.e. - computer work, reading, writing)?
    6. Do you experience dizziness, light-headedness, or nausea while performing far-distance activities (i.e. - driving, television, movies)?
    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?
    8. Do you feel unsteady with walking, or drift to one side while walking?
    9. Do you feel overwhelmed or anxious while walking in a large department store (i.e. – Target, Wal-Mart, etc.)?
    10. Do you feel overwhelmed or anxious when in a crowd?
    11. Does riding in a car make you feel dizzy or uncomfortable?
    12. Do you experience anxiety or nervousness because of your dizziness?
    13. Do you ever find yourself with your head tilted to one side?
    14. Do you experience poor depth perception or have difficulty estimating distances accurately?
    15. Do you experience double / overlapping / shadowed vision at far distances?
    16. Do you experience double / overlapping / shadowed vision at near distances?
    17. Do you experience glare or have sensitivity to bright lights?
    18. Do you close or cover one eye with near or far tasks?
    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)?
    20. Do you tire easily with close-up tasks (computer work, reading, writing)?
    21. Do you experience blurred vision with far-distance activities (i.e. - driving, television, movies, chalkboard at school)?
    22. Do you experience blurred vision with close-up activities (i.e. - computer work, reading, writing)?
    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)?
    24. Do you experience words running together with reading?
    25. Do you experience difficulty with reading or reading comprehension?
  • 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)
    012345678910
    Dizziness
    Nausea
    Anxiety
    Headache
    Neckache
    Unsteady with Walking
    Sensitivity to Light
    Reading Difficulty
  • Have you ever been diagnosed with:
    YesNo
    Traumatic brain injury or concussion (TBI)?
    Reading disability?
    Lazy Eye?
    Have you ever had an eye operation?
  • If you want to tell us more about you symptoms, or if you have specific questions, record them here:

  • Please help us help others by using this box to be very specific about how you found us

  • Examples include:
    If you found us by Internet search, what key words did you use?
    If you were referred, who specifically referred you?
    If you found out about us on a blog or forum or social media site, specifically which one was it?
    Other: Please explain | Heard about us - where?

  • To help us better serve you, please provide the following information:

  • Date Format: MM slash DD slash YYYY