ADULT QUESTIONNAIRE
This questionnaire will help us determine if a misalignment of the eyes called Binocular Vision Dysfunction could be causing your headaches, dizziness and other symptoms.
Binocular Vision Dysfunction can be treated with micro-prismatic eyeglasses that put your eyes back into alignment, reduce eye muscle strain and alleviate most of your symptoms.
Please complete the adult questionnaire if you are 14 years or older and the pediatric questionnaire if you are 13 years or younger.
If you are 13 years old or younger, please click here.
We will interpret your responses and contact you regarding the results.
Please Note: We will not sell or otherwise use information on this form except in addressing your inquiry. Please see our Privacy Policy.