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Home » Contact Us » Pediatric Binocular Vision Dysfunction Questionnaire

Pediatric Binocular Vision Dysfunction Questionnaire

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.

Step 1 of 9

  • Please note: This questionnaire is for someone younger than 14 years old.
    If you are 14 years old or older, 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: 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