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

Do you have headaches and / or facial pain?*

Do you have pain in your eyes with eye movement?*

Do you experience neck or shoulder discomfort?*

Do you have dizziness and / or lightheadedness?*

Do you experience dizziness, light-headedness, or nausea while performing close-up activities (i.e. - computer work, reading, writing)?*

Do you experience dizziness, light-headedness, or nausea while performing far-distance activities (i.e. - driving, television, movies)?*

Do you experience dizziness, light-headedness, or nausea when bending down and standing back up, or when getting up quickly from a seated position?*

Do you feel unsteady with walking, or drift to one side while walking?.*

Do you feel overwhelmed or anxious while walking in a large department store (i.e. – Target, Wal-Mart, etc.)?*

Do you feel overwhelmed or anxious when in a crowd?*

Does riding in a car make you feel dizzy or uncomfortable?*

Do you experience anxiety or nervousness because of your dizziness?*

Do you ever find yourself with your head tilted to one side?*

Do you experience poor depth perception or have difficulty estimating distances accurately?*

Do you experience double / overlapping / shadowed vision at far distances?*

Do you experience glare or have sensitivity to bright lights?*

Do you close or cover one eye with near or far tasks?*

Do you close or cover one eye with near or far tasks?*

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)?*

Do you tire easily with close-up tasks (computer work, reading, writing)?*

Do you experience blurred vision with far-distance activities (i.e. - driving, television, movies, chalkboard at school)?*

Do you experience blurred vision with close-up activities (i.e. - computer work, reading, writing)?*

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)?*

Do you experience words running together with reading?*

Do you experience difficulty with reading or reading comprehension?*

Part 2: Level of Discomfort

On an average day, how much are you bothered by the 8 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*

Nausea*

Anxiety*

Headache*

Neckache*

Unsteady with Walking*

Sensitivity to Light*

Reading Difficulty*

Part 3: History

Have you ever been diagnosed with...

Lazy Eye*

Have you ever had an eye operation?*

Child's Full Name

Age of your Child*

Comment Section:

If you want to tell us more about your symptoms, or if you have specific questions, record them here. (Optional)

How did you find us?*

Please tell us a little more about how you found us:

Examples include:

• Internet search: what keywords did you use?

• Referred by a friend or Professional: who specifically referred you?

• Blog or Forum or Social Media: specifically which one was it?

• Other: Please explain | Heard about us - where?

Please provide the most reliable contact information so we can send you your results and best help you.

Full Name*

Age*

Complete Address ( County, State, City Zipcode (Postal Code)*

What time of day would work best for someone to reach out to you to discuss your Binocular Vision Dysfunction symptoms and answer your questions?*

Phone Number.*

Email*

So we can send a follow up email with additional information along with your child's test results.