Youth Binocular Vision Dysfunction Questionnaire Please note: This questionnaire is for individuals that are 9-13 years old. If your child is 4-8 years old, please click here. If you are 14 years or older, please click here. Youth Binocular Vision Dysfunction Questionnaire For Ages 9-13 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. Directions: Children - answer these questions together with your Parents. For every question, select 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 Symptoms*AlwaysFrequentlyOccasionallyNever1. Do you have headaches or stomach aches or do you get nervous/anxious at school?2. While reading or watching video in a car, do you get a headache or stomach ache or feel unwell?3. Do you get sick to your stomach or nauseous on swings or circular rides?4. Do you have difficulty playing sports, or doing gymnastics or dance?5. Do you have trouble catching baseballs or footballs or Frisbees?6. When you are walking, do you bump into people or furniture or door frames?7. Are you anxious or nervous?8. Does it take you a long time to finish your homework?9. Do you have to read the same thing a couple of times to really understand it?10. When reading, do you skip lines or lose your place OR do you use a guide (finger, ruler or a piece of paper) to help you keep your place?11. When you read, does it look like the letters are moving OR does it seem like words are bumping into each other?12. Do bright lights hurt your eyes?13. Do you close or cover one eye to make it easier to see?14. Do you ever see two of everything (double vision)?15. When reading or working on the computer or electronic device, do your eyes feel tired or does your vision get blurry?16. When looking at the blackboard at school, do your eyes feel tired or does your vision get blurry? Previous Diagnosis Mom / Dad: Has your child ever been diagnosed with any of the following?History*YesNoLearning disability (LD)?Dyslexia?Torticollis?Lazy eye?ADD / ADHD?Migraines or headache?Traumatic brain injury or concussion?Does your child blink their eyes a lot / much more then most children?Are your child’s verbal skills far ahead of their reading skills?Has your child ever had an eye operation? Level of DiscomfortDiscomfort*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)012345678910DizzinessNauseaAnxietyHeadacheNeckacheUnsteady with WalkingSensitivity to LightReading DifficultyAdditional SymptomsIf you would like to tell us more about your symptoms, please write about 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? To help us better serve you, please provide the following information:Name* First Last Email* Best Phone Number*Age*12345678910111213Country*United StatesCanadaAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabweState (USA)*AlaskaAlabamaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificProvince (Canada)*AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland & LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukonCityZipcode*ATTENTIONUpon clicking "Submit" you will be redirected to an Acknowledgement Page. If you are not redirected, then your Questionnaire was NOT SUBMITTED. Please review all red highlighted errors for omissions and correct.CAPTCHAEmailThis field is for validation purposes and should be left unchanged.