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.

	0	1	2	3	4	5	6	7	8	9	10

0 is None, 10 is Worst

	0	1	2	3	4	5	6	7	8	9	10

0 is None, 10 is Worst

	0	1	2	3	4	5	6	7	8	9	10

0 is None, 10 is Worst

	0	1	2	3	4	5	6	7	8	9	10

0 is None, 10 is Worst

	0	1	2	3	4	5	6	7	8	9	10

0 is None, 10 is Worst

	0	1	2	3	4	5	6	7	8	9	10

0 is None, 10 is Worst

	0	1	2	3	4	5	6	7	8	9	10

0 is None, 10 is Worst

	0	1	2	3	4	5	6	7	8	9	10

0 is None, 10 is Worst

	0	1	2	3	4	5	6	7	8	9	10

0 is None, 10 is Worst

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

AlwaysFrequentlyOccasionallyNever

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

Part 4: Health History

Have you ever been diagnosed with or experienced...

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

It helped a lotIt helped mediumIt helped a littleNot helpful

C. Symptoms and Diagnoses

D. Childhood History

CarsickTrouble with reading speed or comprehensionDizzy spellsNone of the above

E. Vision and Eye Care

OptometristOphthalmologistNeither

F. Financial and Daily Activity

Not at allMarginallyModerately (I need to prioritize healthcare choices with the highest impact on health/quality of life)High (I find it difficult or impossible to afford healthcare)

Part 1: Level of Discomfort

Part 2: Frequency of Your Symptoms

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

Part 4: Health History

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

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