Binocular Vision Dysfunction Test

Binocular Vision Dysfunction Test

This questionnaire is designed to identify individuals whose symptoms (ex. headache, dizziness, anxiety, etc.) may be due to vision misalignment (aka Binocular Vision Dysfunction).

Do you have headaches and/or facial pain?
Do you have pain in your eyes with eye movement?
Do you experience neck or shoulder discomfort?
Do you have dizziness and/or light headedness?
Do you experience dizziness, light headedness, or nausea while performing close-up activities
(computer work, reading, writing, etc.)?
Do you experience dizziness, light headedness or nausea while performing far-distance activities (driving,
television, movies, etc.)?
Do you experience dizziness, light headedness, or nausea when bending down and standing back up, or when
getting up quickly from a seated position?
Do you feel unsteady or drift to one side while walking?
Do you feel overwhelmed or anxious while walking in a large department store (Target, Wal-Mart, Costco, etc.)?
Do you feel overwhelmed or anxious when in a crowd?
Does riding in a car make you feel dizzy or uncomfortable?
Do you experience anxiety or nervousness because of your dizziness?
Do you ever find yourself with your head tilted to one side?
Do you experience poor depth perception or have difficulty estimating distances accurately?
Do you experience double/overlapping/shadowed vision at far distances?
Do you experience double/overlapping/shadowed vision at near distances?
Do you experience glare or have sensitivity to bright lights?
Do you close or cover one eye with near or far tasks?
Do you skip lines or lose your place when you are reading? Do you use your finger, ruler or other guides to
maintain your position on the page?
Do you tire easily with close-up tasks (computer work, reading, writing)?
Do you experience blurred vision with far-distance activities (driving, television, movies, chalkboard at
school, etc.)?
Do you experience blurred vision with close-up activities (computer work, reading, writing, etc.)?
Do you blink to ‘clear up’ distant objects after working at a desk or working with close-up activities
(computer work, reading, writing, etc.)?
Do you experience words running together while reading?
Do you experience difficulty with reading or reading comprehension?
Dizziness
10 is the worst it could be, and 0 means you have none of that symptom
Nausea
10 is the worst it could be, and 0 means you have none of that symptom
Anxiety
10 is the worst it could be, and 0 means you have none of that symptom
Headache
10 is the worst it could be, and 0 means you have none of that symptom
Neckache
10 is the worst it could be, and 0 means you have none of that symptom
Unsteady when walking
10 is the worst it could be, and 0 means you have none of that symptom
Sensitivity to light
10 is the worst it could be, and 0 means you have none of that symptom
Reading difficulty
10 is the worst it could be, and 0 means you have none of that symptom
Your total vision score 0

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