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Home » Contact Us » Adult Binocular Vision Dysfunction Questionnaire

Adult Binocular Vision Dysfunction Questionnaire

If you think that you 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.
  • Please note: This questionnaire is for those 14 years old or older.
    If you are 13 years old or younger, please click here.

    If you would like to tell us more about your symptoms, please write about them in the Comment Section at the end of the Questionnaire. 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 Note: We will not sell or otherwise use information on this form except in addressing your inquiry.
    (*) indicates a required field.

    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. Please answer every question.

    •Never = Never
    •Occasionally = Less than 1 time / week
    •Frequently = At least 1 time / week
    •Always = Everyday