Adult Binocular Vision Dysfunction Questionnaire Date MM slash DD slash YYYY Name(Required) First Last Date of Birth(Required) MM slash DD slash YYYY Email(Required) Phone (Main)(Required)Phone (Alternative - Optional)Consent(Required) I consent to receive SMS text messages from ATX Optometry. Standard rates may apply. Reply STOP to opt out.Location(Required) City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State 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.Always = Every day Frequently = At least 1 time / week Occasionally = Less than 1 time / week Never = Never1. Do you have headaches and / or facial pain?(Required) Always Frequently Occasionally Never Describe location of discomfort on face or back of head:Rate your discomfort on a scale from 1-10: 1=extremely mild, 10=extremely severe123456789102. Do you have pain in your eyes with eye movement?(Required) Always Frequently Occasionally Never 3. Do you experience neck or shoulder discomfort?(Required) Always Frequently Occasionally Never 4. Do you have dizziness and / or lightheadedness?(Required) Always Frequently Occasionally Never 5. Do you experience dizziness, light-headedness, or nausea while performing close-up activities (i.e. - computer work, reading, writing)?(Required) Always Frequently Occasionally Never 6. Do you experience dizziness, light-headedness, or nausea while performing far-distance activities (i.e. - driving, television, movies)?(Required) Always Frequently Occasionally Never 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?(Required) Always Frequently Occasionally Never 8. Do you feel unsteady with walking, or drift to one side while walking?(Required) Always Frequently Occasionally Never 9. Do you feel overwhelmed or anxious while walking in a large department store (i.e. – Target, Costco, Malls)?(Required) Always Frequently Occasionally Never 10. Do you feel overwhelmed or anxious when in a crowd?(Required) Always Frequently Occasionally Never 11. Does riding in a car make you feel dizzy or uncomfortable?(Required) Always Frequently Occasionally Never 12. Do you experience anxiety or nervousness because of your dizziness?(Required) Always Frequently Occasionally Never 13. Do you ever find yourself with your head tilted to one side?(Required) Always Frequently Occasionally Never 14. Do you experience poor depth perception or have difficulty estimating distances accurately?(Required) Always Frequently Occasionally Never 15. Do you experience double/overlapping/shadowed vision at far distances?(Required) Always Frequently Occasionally Never 16. Do you experience double/overlapping/shadowed vision at near distances?(Required) Always Frequently Occasionally Never 17. Do you experience glare or have sensitivity to bright lights?(Required) Always Frequently Occasionally Never 18. Do you close or cover one eye with near or far tasks?(Required) Always Frequently Occasionally Never 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)?(Required) Always Frequently Occasionally Never 20. Do you tire easily with close-up tasks (computer work, reading, writing)?(Required) Always Frequently Occasionally Never 21. Do you experience blurred vision with far-distance activities (i.e.-driving, television, movies, chalkboard at school)?(Required) Always Frequently Occasionally Never 22. Do you experience blurred vision with close-up activities (i.e.- computer, reading, writing)?(Required) Always Frequently Occasionally Never 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)?(Required) Always Frequently Occasionally Never 24. Do you experience words running together with reading?(Required) Always Frequently Occasionally Never 25. Do you experience difficulty with reading or reading comprehension?(Required) Always Frequently Occasionally Never Traumatic brain injury or concussion?(Required) Yes No History of ear infections?(Required) Yes No Have you ever been diagnosed with a lazy eye? Yes No Reading disability?(Required) Yes No Have you ever had an eye operation?(Required) Yes No On an average day, how much are you bothered by the 8 symptoms listed below? 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.Dizziness =012345678910Nausea =012345678910Anxiety =012345678910Headache =012345678910Neckache =012345678910Unsteady with walking =012345678910Sensitivity to light =012345678910Reading difficulty =012345678910Please record any additional symptoms you may be experiencing or specific concerns that you have about your eyes / vision:Tell us how you found us(Required) Internet Search Referred by a friend Referred by a professional Found us in a forum, blog or social media Other Please help us help others by using this box to be very specific about how you found us:(Required)Examples include: •If you found us by Internet search, what key words did you use? •If you were referred, who specifically referred you? •If you found out about us on a blog or forum or social media site, specifically which one was it? •Other: Please explain | Heard about us - where?CAPTCHA Δ
