KIDS QUESTIONNAIRE
This questionnaire will help us determine if a misalignment of the eyes called Binocular Vision Dysfunction could be causing your childs headaches, dizziness and other symptoms.
The child questionnaire is designed for ages 13 years or younger.
If you are more than 13 years old, 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.