Pediatric Binocular Vision Dysfunction Questionnaire

Name: Family Eye Care
Address: 3111 U.S. 9, Old Bridge, NJ, 08857, US
Telephone: 732-679-2020

If you think that your child 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 someone younger than 14 years old.
If you are 14 years old or older, 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: 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

Symptoms*

	Always	Frequently	Occasionally	Never
1. Do you have headaches or face pain?
2. Do your eyes hurt and/or does it hurt to move your eyes?
3. Do you have neck pain or a stiff neck or upper back pain?
4. Do you have stomachaches or nausea?
5. Do you get car sickness or motion sickness?
6. Did you get sick in the car seat when you were a small child?
7. Do you get sick to your stomach or nauseous on swings or circular rides?
8. Does riding in the car give you headaches or stomach aches?
9. Do you have trouble reading in the car?
10. Do you feel clumsy or klutzy or uncoordinated?
11. When you are walking, do you bump into people or furniture or door frames?
12. Do you feel funny or dizzy when you bend over and stand back up quickly?
13. Are you anxious or nervous?
14. In grocery stores or malls, do you stay close (cling) to your Mom or Dad? (Do you feel uncomfortable in grocery stores or malls?)
15. Do you tend to play alone or with just a few other kids? (Do you tend to play apart from the main group of kids?)
16. Is reading hard for you or are you a slow reader?
17. Do you have to read the same thing a couple of times to really understand it?
18. Do you use your finger or a ruler or a piece of paper to help you keep your place when you are reading?
19. Do you skip lines or lose your place when you are reading?
20. When you read, does it look like the letters are moving OR does it seem like words are bumping into each other?
21. Do bright lights hurt your eyes?
22. Do you close or cover one eye to make it easier to see?
23. Do you have trouble catching baseballs or footballs or Frisbees?
24. Do you ever see two of everything (double vision)?
25. Is it hard for you to watch 3-D movies?
26. When reading or working on the computer, do your eyes feel tired or does your vision get blurry?
27. When looking at the blackboard at school, do your eyes feel tired or does your vision get blurry?

Previous Diagnosis*

Mom / Dad: Has your child ever been diagnosed with any of the following?

	Yes	No
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?
Are your child’s verbal skills far ahead of their reading skills?
Has your child ever had an eye operation?

Level of 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)
0 1 2 3 4 5 6 7 8 9 10
Dizziness
Nausea
Anxiety
Headache
Neckache
Unsteady with Walking
Sensitivity to Light
Reading Difficulty
Additional Symptoms
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
Please tell us how you found us?*
- Internet Search
- Referred by a friend
- Referred by a professional
- Found us in a forum, blog or social media
Explain:*
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:
Have You Been To The Practice Before?*
- New Patient
- Returning Patient
Name*
First Last
Email*
Best Phone Number*
Back-up Phone Number*
Date of Birth*
MM slash DD slash YYYY
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Age
Country*

Pediatric Binocular Vision Dysfunction Questionnaire

Pediatric Binocular Vision Dysfunction Questionnaire

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

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

Steffani Viveros, OD, FAAO

S. Moshe Roth, OD, FOVDR

	0	1	2	3	4	5	6	7	8	9	10
Dizziness
Nausea
Anxiety
Headache
Neckache
Unsteady with Walking
Sensitivity to Light
Reading Difficulty