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Welcome
Welcome to our Binocular Vision Dysfunction (BVD) Quality of Life questionnaire. This assessment is designed to help identify symptoms that may be related to BVD and guide you towards the next steps for better vision health.
5
Questions
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1
Struggles with Up-Close Activities
*
This field is required.
Tasks that involve up-close objects or activities can be challenging with Binocular Vision Dysfunction (BVD). Please indicate below how often you or your child experience the following symptoms.
Never
Seldom
Occasional
Frequently
Always
1. Headaches with near work
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
2. Words run together when reading
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Row 1, Column 4
3. Burning, itchy, or watery eyes
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Row 2, Column 4
4. Skipping/repeating lines while reading
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
Row 3, Column 4
5. Tilting head or closing one eye when reading
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Row 4, Column 3
Row 4, Column 4
6. Difficulty switching vision from far to near
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Row 5, Column 3
Row 5, Column 4
7. Avoiding near work or reading
Row 6, Column 0
Row 6, Column 1
Row 6, Column 2
Row 6, Column 3
Row 6, Column 4
8. Skipping over small words when reading
Row 7, Column 0
Row 7, Column 1
Row 7, Column 2
Row 7, Column 3
Row 7, Column 4
9. Writing uphill or downhill / slanted
Row 8, Column 0
Row 8, Column 1
Row 8, Column 2
Row 8, Column 3
Row 8, Column 4
10. Misaligns digits/columns of numbers
Row 9, Column 0
Row 9, Column 1
Row 9, Column 2
Row 9, Column 3
Row 9, Column 4
11. Poor reading comprehension
Row 10, Column 0
Row 10, Column 1
Row 10, Column 2
Row 10, Column 3
Row 10, Column 4
12. Holding books or near work very close to eyes
Row 11, Column 0
Row 11, Column 1
Row 11, Column 2
Row 11, Column 3
Row 11, Column 4
13. Short attention span with near work
Row 12, Column 0
Row 12, Column 1
Row 12, Column 2
Row 12, Column 3
Row 12, Column 4
14. Difficulty completing assignments on time
Row 13, Column 0
Row 13, Column 1
Row 13, Column 2
Row 13, Column 3
Row 13, Column 4
15. Saying "I can't" before trying something
Row 14, Column 0
Row 14, Column 1
Row 14, Column 2
Row 14, Column 3
Row 14, Column 4
16. Clumsiness and knocking things over
Row 15, Column 0
Row 15, Column 1
Row 15, Column 2
Row 15, Column 3
Row 15, Column 4
17. Poor use of time
Row 16, Column 0
Row 16, Column 1
Row 16, Column 2
Row 16, Column 3
Row 16, Column 4
18. Losing belonging or misplacing things
Row 17, Column 0
Row 17, Column 1
Row 17, Column 2
Row 17, Column 3
Row 17, Column 4
19. Forgetting things or having poor memory
Row 18, Column 0
Row 18, Column 1
Row 18, Column 2
Row 18, Column 3
Row 18, Column 4
1. Headaches with near work
2. Words run together when reading
3. Burning, itchy, or watery eyes
4. Skipping/repeating lines while reading
5. Tilting head or closing one eye when reading
6. Difficulty switching vision from far to near
7. Avoiding near work or reading
8. Skipping over small words when reading
9. Writing uphill or downhill / slanted
10. Misaligns digits/columns of numbers
11. Poor reading comprehension
12. Holding books or near work very close to eyes
13. Short attention span with near work
14. Difficulty completing assignments on time
15. Saying "I can't" before trying something
16. Clumsiness and knocking things over
17. Poor use of time
18. Losing belonging or misplacing things
19. Forgetting things or having poor memory
Never
Row 0, Column 0
Seldom
Row 0, Column 1
Occasional
Row 0, Column 2
Frequently
Row 0, Column 3
Always
Row 0, Column 4
Never
Row 1, Column 0
Seldom
Row 1, Column 1
Occasional
Row 1, Column 2
Frequently
Row 1, Column 3
Always
Row 1, Column 4
Never
Row 2, Column 0
Seldom
Row 2, Column 1
Occasional
Row 2, Column 2
Frequently
Row 2, Column 3
Always
Row 2, Column 4
Never
Row 3, Column 0
Seldom
Row 3, Column 1
Occasional
Row 3, Column 2
Frequently
Row 3, Column 3
Always
Row 3, Column 4
Never
Row 4, Column 0
Seldom
Row 4, Column 1
Occasional
Row 4, Column 2
Frequently
Row 4, Column 3
Always
Row 4, Column 4
Never
Row 5, Column 0
Seldom
Row 5, Column 1
Occasional
Row 5, Column 2
Frequently
Row 5, Column 3
Always
Row 5, Column 4
Never
Row 6, Column 0
Seldom
Row 6, Column 1
Occasional
Row 6, Column 2
Frequently
Row 6, Column 3
Always
Row 6, Column 4
Never
Row 7, Column 0
Seldom
Row 7, Column 1
Occasional
Row 7, Column 2
Frequently
Row 7, Column 3
Always
Row 7, Column 4
Never
Row 8, Column 0
Seldom
Row 8, Column 1
Occasional
Row 8, Column 2
Frequently
Row 8, Column 3
Always
Row 8, Column 4
Never
Row 9, Column 0
Seldom
Row 9, Column 1
Occasional
Row 9, Column 2
Frequently
Row 9, Column 3
Always
Row 9, Column 4
Never
Row 10, Column 0
Seldom
Row 10, Column 1
Occasional
Row 10, Column 2
Frequently
Row 10, Column 3
Always
Row 10, Column 4
Never
Row 11, Column 0
Seldom
Row 11, Column 1
Occasional
Row 11, Column 2
Frequently
Row 11, Column 3
Always
Row 11, Column 4
Never
Row 12, Column 0
Seldom
Row 12, Column 1
Occasional
Row 12, Column 2
Frequently
Row 12, Column 3
Always
Row 12, Column 4
Never
Row 13, Column 0
Seldom
Row 13, Column 1
Occasional
Row 13, Column 2
Frequently
Row 13, Column 3
Always
Row 13, Column 4
Never
Row 14, Column 0
Seldom
Row 14, Column 1
Occasional
Row 14, Column 2
Frequently
Row 14, Column 3
Always
Row 14, Column 4
Never
Row 15, Column 0
Seldom
Row 15, Column 1
Occasional
Row 15, Column 2
Frequently
Row 15, Column 3
Always
Row 15, Column 4
Never
Row 16, Column 0
Seldom
Row 16, Column 1
Occasional
Row 16, Column 2
Frequently
Row 16, Column 3
Always
Row 16, Column 4
Never
Row 17, Column 0
Seldom
Row 17, Column 1
Occasional
Row 17, Column 2
Frequently
Row 17, Column 3
Always
Row 17, Column 4
Never
Row 18, Column 0
Seldom
Row 18, Column 1
Occasional
Row 18, Column 2
Frequently
Row 18, Column 3
Always
Row 18, Column 4
1
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2
Struggles with Distant Activities
*
This field is required.
Tasks that involve distant objects or activities can be challenging with Binocular Vision Dysfunction (BVD). Please indicate below how often you or your child experience the following symptoms.
Never
Seldom
Occasional
Frequently
Always
1. Headaches or facial pain
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
2. Pain in eyes with eye movement
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Row 1, Column 4
3. Neck or shoulder discomfort
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Row 2, Column 4
4. Dizziness, light-headedness or nausea while driving, watching tv, or changing positions
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
Row 3, Column 4
5. Dizziness, light-headedness or nausea while riding in a car, boat, or airplane
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Row 4, Column 3
Row 4, Column 4
6. Unsteady walk or drift to one side while walking
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Row 5, Column 3
Row 5, Column 4
7. Feeling overwhelmed or anxious while in department stores or in a crowd
Row 6, Column 0
Row 6, Column 1
Row 6, Column 2
Row 6, Column 3
Row 6, Column 4
8. Feeling of anxiety or panic attacks
Row 7, Column 0
Row 7, Column 1
Row 7, Column 2
Row 7, Column 3
Row 7, Column 4
9. Tilting or turning head for comfort
Row 8, Column 0
Row 8, Column 1
Row 8, Column 2
Row 8, Column 3
Row 8, Column 4
10. Poor depth perception or difficulty judging distances
Row 9, Column 0
Row 9, Column 1
Row 9, Column 2
Row 9, Column 3
Row 9, Column 4
11. Double, shadowed or overlapping vision
Row 10, Column 0
Row 10, Column 1
Row 10, Column 2
Row 10, Column 3
Row 10, Column 4
12. Blurry vision or vision that goes in and out of focus
Row 11, Column 0
Row 11, Column 1
Row 11, Column 2
Row 11, Column 3
Row 11, Column 4
13. Glare or light sensitivity
Row 12, Column 0
Row 12, Column 1
Row 12, Column 2
Row 12, Column 3
Row 12, Column 4
14. Closing one eye for comfort
Row 13, Column 0
Row 13, Column 1
Row 13, Column 2
Row 13, Column 3
Row 13, Column 4
15. Feeling tired, fatigued, sleepy or yawn excessively
Row 14, Column 0
Row 14, Column 1
Row 14, Column 2
Row 14, Column 3
Row 14, Column 4
16. Blink excessively to clear up focus
Row 15, Column 0
Row 15, Column 1
Row 15, Column 2
Row 15, Column 3
Row 15, Column 4
17. Difficulty adjusting to new prescriptions
Row 16, Column 0
Row 16, Column 1
Row 16, Column 2
Row 16, Column 3
Row 16, Column 4
18. Difficulty maintaining eye contact
Row 17, Column 0
Row 17, Column 1
Row 17, Column 2
Row 17, Column 3
Row 17, Column 4
19. Feeling unfocused or spaced out
Row 18, Column 0
Row 18, Column 1
Row 18, Column 2
Row 18, Column 3
Row 18, Column 4
1. Headaches or facial pain
2. Pain in eyes with eye movement
3. Neck or shoulder discomfort
4. Dizziness, light-headedness or nausea while driving, watching tv, or changing positions
5. Dizziness, light-headedness or nausea while riding in a car, boat, or airplane
6. Unsteady walk or drift to one side while walking
7. Feeling overwhelmed or anxious while in department stores or in a crowd
8. Feeling of anxiety or panic attacks
9. Tilting or turning head for comfort
10. Poor depth perception or difficulty judging distances
11. Double, shadowed or overlapping vision
12. Blurry vision or vision that goes in and out of focus
13. Glare or light sensitivity
14. Closing one eye for comfort
15. Feeling tired, fatigued, sleepy or yawn excessively
16. Blink excessively to clear up focus
17. Difficulty adjusting to new prescriptions
18. Difficulty maintaining eye contact
19. Feeling unfocused or spaced out
Never
Row 0, Column 0
Seldom
Row 0, Column 1
Occasional
Row 0, Column 2
Frequently
Row 0, Column 3
Always
Row 0, Column 4
Never
Row 1, Column 0
Seldom
Row 1, Column 1
Occasional
Row 1, Column 2
Frequently
Row 1, Column 3
Always
Row 1, Column 4
Never
Row 2, Column 0
Seldom
Row 2, Column 1
Occasional
Row 2, Column 2
Frequently
Row 2, Column 3
Always
Row 2, Column 4
Never
Row 3, Column 0
Seldom
Row 3, Column 1
Occasional
Row 3, Column 2
Frequently
Row 3, Column 3
Always
Row 3, Column 4
Never
Row 4, Column 0
Seldom
Row 4, Column 1
Occasional
Row 4, Column 2
Frequently
Row 4, Column 3
Always
Row 4, Column 4
Never
Row 5, Column 0
Seldom
Row 5, Column 1
Occasional
Row 5, Column 2
Frequently
Row 5, Column 3
Always
Row 5, Column 4
Never
Row 6, Column 0
Seldom
Row 6, Column 1
Occasional
Row 6, Column 2
Frequently
Row 6, Column 3
Always
Row 6, Column 4
Never
Row 7, Column 0
Seldom
Row 7, Column 1
Occasional
Row 7, Column 2
Frequently
Row 7, Column 3
Always
Row 7, Column 4
Never
Row 8, Column 0
Seldom
Row 8, Column 1
Occasional
Row 8, Column 2
Frequently
Row 8, Column 3
Always
Row 8, Column 4
Never
Row 9, Column 0
Seldom
Row 9, Column 1
Occasional
Row 9, Column 2
Frequently
Row 9, Column 3
Always
Row 9, Column 4
Never
Row 10, Column 0
Seldom
Row 10, Column 1
Occasional
Row 10, Column 2
Frequently
Row 10, Column 3
Always
Row 10, Column 4
Never
Row 11, Column 0
Seldom
Row 11, Column 1
Occasional
Row 11, Column 2
Frequently
Row 11, Column 3
Always
Row 11, Column 4
Never
Row 12, Column 0
Seldom
Row 12, Column 1
Occasional
Row 12, Column 2
Frequently
Row 12, Column 3
Always
Row 12, Column 4
Never
Row 13, Column 0
Seldom
Row 13, Column 1
Occasional
Row 13, Column 2
Frequently
Row 13, Column 3
Always
Row 13, Column 4
Never
Row 14, Column 0
Seldom
Row 14, Column 1
Occasional
Row 14, Column 2
Frequently
Row 14, Column 3
Always
Row 14, Column 4
Never
Row 15, Column 0
Seldom
Row 15, Column 1
Occasional
Row 15, Column 2
Frequently
Row 15, Column 3
Always
Row 15, Column 4
Never
Row 16, Column 0
Seldom
Row 16, Column 1
Occasional
Row 16, Column 2
Frequently
Row 16, Column 3
Always
Row 16, Column 4
Never
Row 17, Column 0
Seldom
Row 17, Column 1
Occasional
Row 17, Column 2
Frequently
Row 17, Column 3
Always
Row 17, Column 4
Never
Row 18, Column 0
Seldom
Row 18, Column 1
Occasional
Row 18, Column 2
Frequently
Row 18, Column 3
Always
Row 18, Column 4
1
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3
Name
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First Name
Last Name
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Email
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example@example.com
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Phone Number
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6
Your Score
If you scored higher than 38, you may likely have a binocular vision dysfunction.
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7
1. Headaches or facial pain
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2. Words running together
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9
3. Burning, itchy, or watery eyes
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10
4. Skipping/repeating lines
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11
5. Tilting head or closing one eye
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12
6. Difficulty switching vision from far to near
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13
7. Avoiding near work
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14
8. Skipping over small words when reading
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15
9. Writing uphill/downhill
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16
10. Misaligns digits/columns of numbers
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17
11. Poor reading comprehension
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18
12. Holding books or near work close to eyes
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13. Short attention span
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14. Difficulty completing assignments
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15. Saying I can't before trying
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16. Clumsiness
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17. Poor use of time
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18. Losing belongings or misplacing things
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19. Forgetting things or having poor memory
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1. Headaches or facial pain
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2. Pain with eye movements
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28
3. Neck or shoulder discomfort
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29
4. Dizziness or nausea while driving or watching tv
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30
5. Dizziness or nausea while on a car, boat, or plane
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31
6. Unsteady walk or drift to one side
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32
7. Feeling overwhelmed or anxious while in department stores or in crowd
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8. Feeling of anxiety or panic attack
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9. Tilting or turning head for comfort
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35
10. Poor depth perception or difficulty judging distances
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36
11. Double or shadowed vision
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37
12. Vision in and out of focus
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38
13. Glare or light sensitivity
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39
14. Closing one eye for comfort
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40
15. Feeling tired, fatigue, sleepy, or yawn
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41
16. Blink excessively to clear up focus
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17. Difficulty adjusting to new prescriptions
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43
18. Difficulty maintaining eye contact
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19. Feeling unfocused or spaced out
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