BVDQ QUESTIONNAIRE

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.
(ex. 8:30am)


(ex. mm/dd/yy)
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 2 time / week
  •     Always = More than 3 time / week
Have you ever been diagnosed with:

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)

Dizziness =      /    10
Nausea =      /    10
Anxiety =      /    10
Headache =      /    10
Neckache =      /    10
Unsteady with walking =      /    10
Sensitivity to light =      /    10
Reading Difficulty =      /    10
Comment Section: If you want to tell us more about you symptoms, or if you have specific questions, record them here:
Please Note: We will not sell or otherwise use information on this form except in addressing your inquiry.

Total 25:

Total 8:

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