Functional Vision Survey

Functional Vision Survey

If you or your child is having vision problems more serious than just clarity of vision, this survey may help determine if a binocular vision evaluation is recommended. We are experienced in treating binocular vision deficiencies & other visual disturbances requiring specialized care.
During a Binocular Vision consultation, you or your child's eyes will be assessed for how well they work together and how they may be affecting your ability to focus efficiently and effectively. The inability of the eyes to work together may be acquired or naturally occurring, often becoming apparent when reading or near-work intensifies.

Click the button besides each question below that best describes your answer. Your score will be shown below. You may print the form or submit your information to our office upon scheduling an appointment for a comprehensive eye exam if you haven't had one recently or for a binocular vision consultation to address your specific needs.

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How often do the following happen? *

Never

A little

Sometimes

A lot

Always

1. Headaches during school or homework

2. Words move or get blurry when reading

3. Rubs eyes during close work

4. Fatigues quickly during reading and homework

5. Head tilt or closes an eye when reading

6. Loses place while reading

7. Avoids reading or writing activities

8. Leaves out small words when reading

9. Uses finger during reading

10. Burning, red or watery eyes after reading

11. Poor reading comprehension/ has trouble remembering what was read

12. Reading or writing distance too close

13. Complains that eyes hurt during reading or homework

14. Difficulty copying from the board

15. Leaves out problems on tests or worksheets

16. Homework takes too long/ classroom assignments do not get finished on time

Total Score:
* Total score greater than 20 indicates you or your child is at higher risk for a binocular vision disorder which may impact functional vision and learning. Further evaluation by a pediatric optometrist is recommended.
Answers may be printed for your records by clicking the "Print" button below.
You may also fill in your contact details below and hit the "Submit to our Office" button to forward your information to us in preparation for your next appointment. To schedule an appointment online, click here, or call our office at 212.410.1291
Name *

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