optikpdx.com - BVD Questionnaire for Ages 9-13

Binocular Vision Dysfunction Questionnaire (BVDQ™)

SCREENING QUESTIONNAIRE - For Ages 9-13
Child’s Name
Parent/Guardian’s Name
Date

MonthDayYear
Date
Phone Number
Please enter a valid phone number.
Email
example@example.com
Birthdate/Age
Location(City, State)
Directions: Children - answer these questions together with your Parent/Guardian. 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.

Always = every day

Frequently = at least once per week

Occasionally = less than once per week

Never = never

Select an appropriate answer

	Always (3)	Frequently (2)	Occasionally (1)	Never (0)
1. Do you have headaches or stomach aches or do you get nervous/anxious at school?
2. While reading or watching video in a car, do you get a headache or stomach ache or feel unwell?
3. Do you get sick to your stomach or nauseous on swings or circular rides?
4. Do you have difficulty playing sports, or doing gymnastics or dance?
5. Do you have trouble catching baseballs or footballs or Frisbees
6. When you are walking, do you bump into people or furniture or door frames?
7. Are you anxious or nervous?
8. Does it take you a long time to finish your homework?
9. Do you have to read the same thing a couple of times to really understand it?
10. When reading, do you skip lines or lose your place OR do you use a guide (finger, ruler or a piece of paper) to help you keep your place?
11. When you read, does it look like the letters are moving OR does it seem like words are bumping into each other?
12. Do bright lights hurt your eyes?
13. Do you close or cover one eye to make it easier to see?
14. Do you ever see two of everything (double vision)?
15. When reading or working on the computer or electronic device, do your eyes feel tired or does your vision get blurry?
16. When looking at the blackboard at school, do your eyes feel tired or does your vision get blurry?

Totals:
This questionnaire is designed to identify individuals whose symptoms (ex. headache, dizziness, anxiety, etc.) may be due to vision misalignment.
Consider an evaluation by a NeuroVisual Specialist if the score is 10 or greater.

Parent/Guardian: Has your child ever been diagnosed with:

	YES	NO
Learning Disability (LD)?
Dyslexia?
Torticollis?
Lazy eye?
ADD/ADHD?
Migraines or headache?
Traumatic brain injury or concussion?
Does your child blink his/her eyes a lot/much more than most children?
Are your child’s verbal skills far ahead of his/her reading skills?
Has your child ever had an eye operation?

On an average day, how much are you bothered by symptoms listed here?

Rate each symptom from 0 -10
0 = None of that symptom
10 = Worst
Dizziness

0

1

2

3

4

5

6

7

8

9

10

0 is None, 10 is Worst
Nausea

0

1

2

3

4

5

6

7

8

9

10

0 is None, 10 is Worst
Anxiety

0

1

2

3

4

5

6

7

8

9

10

0 is None, 10 is Worst
Headache

0

1

2

3

4

5

6

7

8

9

10

0 is None, 10 is Worst
Neckache

0

1

2

3

4

5

6

7

8

9

10

0 is None, 10 is Worst
Unsteady when walking

0

1

2

3

4

5

6

7

8

9

10

0 is None, 10 is Worst
Sensitivity to light

0

1

2

3

4

5

6

7

8

9

10

0 is None, 10 is Worst
Reading difficulty

0

1

2

3

4

5

6

7

8

9

10

0 is None, 10 is Worst
Sound sensitivity

0

1

2

3

4

5

6

7

8

9

10

0 is None, 10 is Worst
Please record any additional symptoms your child may be experiencing or specific concerns that you may have about your child’s eyes/vision:
This questionnaire is designed to screen for those who may have difficulty with vision alignment. The information obtained herein is considered a preliminary result only and does not diagnose or constitute confirmation of any vision problems. It is not a substitute for a NeuroVisual examination. Since vision changes can occur without visible indications, most eye care professionals and medical authorities recommend a vision exam annually.
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Binocular Vision Dysfunction Questionnaire (BVDQ™)