• Welcome to the Dizziness and Binocular Vision Dysfunction (BVD) Survey!

     
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  • Part 1: Level of Discomfort

    On an average day (or if you get your symptoms only episodically, on an average day during an episode), how much are you bothered by the 9 symptoms listed below?

    Directions:  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.

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  • Part 2: Frequency of Your Symptoms

    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 1 time / week
    • Always = Everyday

  • 1. Do you have headaches and / or facial pain?*
  • 2. Do you have pain in your eyes with eye movement?*
  • 3. Do you experience neck or shoulder discomfort?*
  • 4. Do you have dizziness and / or lightheadedness?*
  • 5. Do you experience dizziness, light-headedness, or nausea while performing close-up activities (i.e. - computer work, reading, writing)?*
  • 6. Do you experience dizziness, light-headedness, or nausea while performing far-distance activities (i.e. - driving, television, movies)?*
  • 7. Do you experience dizziness, light-headedness, or nausea when bending down and standing back up, or when getting up quickly from a seated position?*
  • 8. Do you feel unsteady with walking, or drift to one side while walking?*
  • 9. Do you feel overwhelmed or anxious while walking in a large department store (i.e. – Target, Wal-Mart, etc.)?*
  • 10. Do you feel overwhelmed or anxious when in a crowd?*
  • 11. Does riding in a car make you feel dizzy or uncomfortable?*
  • 12. Do you experience anxiety or nervousness because of your dizziness?*
  • 13. Do you ever find yourself with your head tilted to one side?*
  • 14. Do you experience poor depth perception or have difficulty estimating distances accurately?*
  • 15. Do you experience double / overlapping / shadowed vision at far distances?*
  • 16. Do you experience double / overlapping / shadowed vision at near distances?*
  • 17. Do you experience glare or have sensitivity to bright lights?*
  • 18. Do you close or cover one eye with near or far tasks?*
  • 19. Do you skip lines or lose your place while reading (do you use your finger or a ruler or other guides to maintain your position on the page)?*
  • 20. Do you tire easily with close-up tasks (computer work, reading, writing)?*
  • 21. Do you experience blurred vision with far-distance activities (i.e. - driving, television, movies, chalkboard at school)?*
  • 22. Do you experience blurred vision with close-up activities (i.e. - computer work, reading, writing)?*
  • 23. Do you blink to clear up distant objects after working at a desk or working with close-up activities (i.e. - computer work, reading, writing)?*
  • 24. Do you experience words running together with reading?*
  • 25. Do you experience difficulty with reading or reading comprehension?*

  • Part 3: Dizziness & Sound Symptoms
    On an average day, are you bothered by the following symptoms listed below?

  • Do you have a fast heart rate / palpitations upon standing?*
  • Do you have an intolerance to heat?*
  • Does standing make your dizziness symptoms worse?*
  • If you lie down, is your dizziness reduced?*
  • Do you experience dizziness or notice an increase in dizziness when speaking loudly or in response to loud noises?*
  • Do people mention to you that your speaking voice is soft even though it seems loud to you?*
  • When you cough or sneeze do you feel like things are moving or does it make you dizzy?*
  • Have you ever had the feeling that fluid was leaking out of one of your ears, yet there wasn’t any fluid there?*
  • Are you made uncomfortable by sounds that seem loud to you but not to your friend/ family?*
  • Is your dizziness worse with head movement, particularly when rolling over in bed?*

  • Part 4: Health History

    Have you ever been diagnosed with or experienced...

  • Traumatic Brain Injury / Concussion*
  • Reading Disability*
  • Lazy Eye*
  • Have you ever had an eye operation?*

  • Thank you for your responses so far!  We now would like to ask you about your history with dizziness and various treatments.

  • A. Onset and Cause

  • When did your dizziness start?*
  • Has the cause of your dizziness been found?*
  • If Yes, how long did it take to find the cause of your dizziness?*
  • If No, how long have you been searching for the cause of your dizziness?*
  • How has dizziness impacted your life?*

  • B. Therapies

  • Have you participated in vestibular therapy?*
  • If Yes, how helpful was vestibular therapy?*
  • Have you participated in counseling therapy?*
  • If Yes, how helpful was counseling therapy?*

  • C. Symptoms and Diagnoses

  • Do you currently struggle with any of the following symptoms? (check all that apply)*
  • Have you been told you have any of the following diagnoses? (check all that apply)*

  • D. Childhood History

  • As a child, did you experience any of the following? (check all that apply)*

  • E. Vision and Eye Care

  • Since your dizziness began, select if you have been seen by any of the following doctors (Select all the apply):
  • Were you diagnosed with any of the following? (check all that apply)*
  • Have you ever participated in vision therapy?*
  • If Yes, how helpful was vision therapy?*

  • F. Financial and Daily Activity

  • How has your dizziness impacted your ability to afford care?*
  • How many steps do you take in an average day?*

  • To help us deliver your score, please provide the following information:

    All of your personal information will be stored securely and kept 100% private.
  • Gender (please select):*

  • Highest level of education*
  • Should be Empty: