If you think that you might have Binocular Vision Dysfunction, please fill out this Questionnaire and send it to us after it is completed. 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.