Binocular Optometry

Suffering From Headaches and Dizziness

ADULT QUESTIONNAIRE

Adult Eye Evaluation 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.







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

1. Do you have headaches and / or facial pain?
Never Occasionally Frequently Always
2. Do you have pain in your eyes with eye movement?
Never Occasionally Frequently Always
3. Do you experience neck or shoulder discomfort?
Never Occasionally Frequently Always
4. Do you have dizziness and / or lightheadedness?
Never Occasionally Frequently Always
5. Do you experience dizziness, light-headedness, or nausea while performing close-up activities (i.e. - computer work, reading, writing)?
Never Occasionally Frequently Always
6. Do you experience dizziness, light-headedness, or nausea while performing far-distance activities (i.e. - driving, television, movies)?
Never Occasionally Frequently Always
7. Do you experience dizziness, light-headedness, or nausea when bending down and standing back up, or when getting up quickly from a seated position?
Never Occasionally Frequently Always
8. Do you feel unsteady with walking, or drift to one side while walking?
Never Occasionally Frequently Always
9. Do you feel overwhelmed or anxious while walking in a large department store (i.e. Target, Wal-Mart, Meijer)?
Never Occasionally Frequently Always
10. Do you feel overwhelmed or anxious when in a crowd?
Never Occasionally Frequently Always
11. Does riding in a car make you feel dizzy or uncomfortable?
Never Occasionally Frequently Always
12. Do you experience anxiety or nervousness because of your dizziness?
Never Occasionally Frequently Always
13. Do you ever find yourself with your head tilted to one side?
Never Occasionally Frequently Always
14. Do you experience poor depth perception or have difficulty estimating distances accurately?
Never Occasionally Frequently Always
15. Do you experience double / overlapping / shadowed vision at far distances?
Never Occasionally Frequently Always
16. Do you experience double / overlapping / shadowed vision at near distances?
Never Occasionally Frequently Always
17. Do you experience glare or have sensitivity to bright lights?
Never Occasionally Frequently Always
18. Do you close or cover one eye with near or far tasks?
Never Occasionally Frequently Always
19. Do you skip lines or lose your place while reading (do you use your finger or a ruler or other guides to maintain your position on the page)?
Never Occasionally Frequently Always
20. Do you tire easily with close-up tasks (computer work, reading, writing)?
Never Occasionally Frequently Always
21. Do you experience blurred vision with far-distance activities (i.e. - driving, television, movies, chalkboard at school)?
Never Occasionally Frequently Always
22. Do you experience blurred vision with close-up activities (i.e. - computer work, reading, writing)?
Never Occasionally Frequently Always
23. Do you blink to clear up distant objects after working at a desk or working with close-up activities (i.e. - computer work, reading, writing)?
Never Occasionally Frequently Always
24. Do you experience words running together with reading?
Never Occasionally Frequently Always
25. Do you experience difficulty with reading or reading comprehension?
Never Occasionally Frequently Always

 

Have you ever been diagnosed with:

Traumatic brain injury or concussion (TBI)?
Yes No
Reading disability?
Yes No
Lazy Eye?
Yes No
Have you ever had an eye operation?
Yes No

On an average day, how much are you bothered by the 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)

Dizziness = / 10

Nausea = / 10

Anxiety = / 10

Headache = / 10

Neckache = / 10

Unsteady with Walking = / 10

Sensitivity to Light = / 10

Reading Difficulty = / 10

Comment Section: If you want to tell us more about you symptoms, or if you have specific questions, record them here:

Tell us how you found us.
Internet Search
Referred by a Friend
Referred by a Professional
Forum, Blog or Social Media
Other
Please explain how you found us(*)
Please Note: We will not sell or otherwise use information on this form except in addressing your inquiry. Please see our Privacy Policy




Blackstone Valley Optometry

Copyright © 2018 Blackstone Valley Optometry
All Rights Reserved
385 Mendon Road, Suite 2, Woonsocket, RI 02895
E: This email address is being protected from spambots. You need JavaScript enabled to view it.
Privacy Policy | Site Map

Site Designed by Midfield Technologies