Child Binocular Vision Dysfunction Questionnaire Please note: This questionnaire is for individuals that are 4-8 years old. If your child is 9-13 years old, please click here. If you are 14 years or older, please click here. Child Binocular Vision Dysfunction Questionnaire For Ages 4-8 Years Old If you think that your child might have Binocular Vision Dysfunction, please fill out this Questionnaire and submit to us after completion. We will interpret your responses and contact you regarding the results. (*) indicated a required field. Symptoms*YesNoA. Does your child have difficulty reading or learning OR skip letters or words or lines OR misread words or reverse numbers or words OR lose their place often while reading?B. Does your child have poor handwriting – poor letter sizing (too big or too small), poor spacing, writing lines with an upward or downward slant?C. Does your child avoid near activities OR do they act out after 5-10 minutes if they must perform near activities?D. Does your child sit very close to the TV / monitor / electronic devices OR pull toys very close to their face see them?E. Does your child have difficulty identify shapes, colors, letters, numbers and common images that are age appropriate?F. Does your child walk with difficulty (do they sway, trip or fall OR bump into objects or people) OR avoid climbing on couches or outdoor playscapes?G. Does your child have trouble seeing the board, or seeing up close?H. Does your child have difficulty catching or kicking a ball?I. Does your child have headaches or stomach aches at school, pre-school or when away from home?J. Does your child have light sensitivity (closes/covers eyes in bright light) OR not like bright places?K. Does your child close or cover one eye when doing up close activities?L. Does your child have nervousness or anxiety OR gets startled often OR is clingy in stores?M. Does your child squint or blink or make faces to “see”? Comment Section:If you want to tell us more about your symptoms, or if you have specific questions, record them here. We will combine this information with the responses you gave in the Questionnaire to provide you with a more detailed interpretation of the results. Please help us help others by using this box to be very specific about how you found usPlease tell us how you found us?*Internet SearchReferred by a friendReferred by a professionalFound us in a forum, blog or social mediaExplain:*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? 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