Child Binocular Vision Dysfunction Questionnaire

Child Binocular Vision Dysfunction Questionnaire

Child Binocular Vision Dysfunction Questionnaire

Child Binocular Vision Dysfunction Questionnaire

Please note: This questionnaire is for individuals who are 4-8 years old.
If your child is 9-13 years old, please click here. If you are 14 years or older, please click here.

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.

This test will take about 10 minutes. After completion you will be sent a follow up email with your results and next steps.

Part 1: Symptoms

Does your child have difficulty reading or learning OR skip letters or words or lines OR misread words or reverse numbers or words OR lose their place often while reading?*

Does your child have poor handwriting – poor letter sizing (too big or too small), poor spacing, writing lines with an upward or downward slant?*

Does your child avoid near activities OR do they act out after 5-10 minutes if they must perform near activities?

Does your child sit very close to the TV / monitor / electronic devices OR pull toys very close to their face see them?

Does your child have difficulty identify shapes, colors, letters, numbers and common images that are age appropriate?

Does your child walk with difficulty (do they sway, trip or fall OR bump into objects or people) OR avoid climbing on couches or outdoor playscapes?*

Does your child have trouble seeing the board, or seeing up close?*

Does your child have difficulty catching or kicking a ball?*

Does your child have headaches or stomach aches at school, pre-school or when away from home?*

Does your child have light sensitivity (closes/covers eyes in bright light) OR not like bright places?*

Does your child close or cover one eye when doing up close activities?*

Does your child have nervousness or anxiety OR gets startled often OR is clingy in stores?*

Does your child squint or blink or make faces to “see”?*

Comment Section:

If you want to tell us more about your child's symptoms, or if you have specific questions, record them here. We will combine this information with the responses you entered above to provide you with a more detailed interpretation of the results.

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 your child.

Parent's Full Name/Guardian.*

Child's Full Name

Age of your Child*

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

What is the best time of day for one of our team members to call you to discuss your child's symptoms and answer your questions in the next 2-3 days?*

Parent/Guardian Phone Number.*


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

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