Binocular Vision Dysfunction Questionnaire (BVDQ™) for Adults

Binocular Vision Dysfunction Questionnaire (BVDQ™) For Adults

Name *

Phone *

Email *

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.

Always = every day

Occasionally = less than once per week

Frequently = at least once per week

Never = never

Do you have headaches and/or facial pain? *

Always

Frequently

Occasionally

Never

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

Always

Frequently

Occasionally

Never

Do you experience neck or shoulder discomfort? *

Always

Frequently

Occasionally

Never

Do you have dizziness and/or light headedness? *

Always

Frequently

Occasionally

Never

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

Always

Frequently

Occasionally

Never

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

Always

Frequently

Occasionally

Never

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

Always

Frequently

Occasionally

Never

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

Always

Frequently

Occasionally

Never

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

Always

Frequently

Occasionally

Never

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

Always

Frequently

Occasionally

Never

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

Always

Frequently

Occasionally

Never

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

Always

Frequently

Occasionally

Never

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

Always

Frequently

Occasionally

Never

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

Always

Frequently

Occasionally

Never

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

Always

Frequently

Occasionally

Never

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

Always

Frequently

Occasionally

Never

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

Always

Frequently

Occasionally

Never

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

Always

Frequently

Occasionally

Never

Do you skip lines or lose your place when you are reading? Do you use your finger, ruler or other guides to maintain your position on the page? *

Always

Frequently

Occasionally

Never

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

Always

Frequently

Occasionally

Never

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

Always

Frequently

Occasionally

Never

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

Always

Frequently

Occasionally

Never

Do you blink to 'clear up' distant objects after working at a desk or working with close-up activities (computer work, reading, writing, etc.)? *

Always

Frequently

Occasionally

Never

Do you experience words running together while reading? *

Always

Frequently

Occasionally

Never

Do you experience difficulty with reading or reading comprehension? *

Always

Frequently

Occasionally

Never

Have you ever been diagnosed with a traumatic brain injury (TBI)? *

Yes

No

Have you ever been diagnosed with a concussion? *

Yes

No

Have you ever been diagnosed with a lazy eye? *

Yes

No

Have you ever been diagnosed with a reading disability? *

Yes

No

Have you ever had an eye operation? *

Yes

No

On an average day, how much are you bothered by symptoms listed here?

Rate each symptom from 0 to 10.

0 = None of that symptom

10 = Worst

How much are you bothered by Dizziness? *

0=None

1

2

3

4

5

6

7

8

9

10=Worst

How much are you bothered by Nausea? *

0=None

1

2

3

4

5

6

7

8

9

10=Worst

How much are you bothered by Anxiety? *

0=None

1

2

3

4

5

6

7

8

9

10=Worst

How much are you bothered by Headache? *

0=None

1

2

3

4

5

6

7

8

9

10=Worst

How much are you bothered by Neckache? *

0=None

1

2

3

4

5

6

7

8

9

10=Worst

How much are you bothered by being Unsteady when walking? *

0=None

1

2

3

4

5

6

7

8

9

10=Worst

How much are you bothered by Sensitivity to light? *

0=None

1

2

3

4

5

6

7

8

9

10=Worst

How much are you bothered by Reading difficulty? *

0=None

1

2

3

4

5

6

7

8

9

10=Worst

How much are you bothered by Sound sensitivity? *

0=None

1

2

3

4

5

6

7

8

9

10=Worst

Please record any additional symptoms you may be experiencing or specific concerns that you have about your eyes/vision:

On an average day, are you bothered by the following symptoms listed here? Note your response by checking Yes or No for each.

Do you have a fast heart rate / palpitations upon standing? *

Yes

No

Do you have an intolerance to heat? *

Yes

No

Does standing make your dizziness symptoms worse? *

Yes

No

If you lie down, is your dizziness reduced? *

Yes

No

Do you experience dizziness or notice an increase in dizziness when speaking loudly or in response to loud noises? *

Yes

No

Do people mention to you that your speaking voice is soft even though it seems loud to you? *

Yes

No

When you cough or sneeze do you feel like things are moving or does it make you dizzy? *

Yes

No

Have you ever had the feeling that fluid was leaking out of one of your ears, yet there wasn't any fluid there? *

Yes

No

Are you made uncomfortable by sounds that seem loud to you but not to your friend/family? *

Yes

No

Is your dizziness worse with head movement, particularly when rolling over in bed? *

Yes

No

BVDQ Score (Adult) *

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50% to 70% symptom

improvement

25 years of

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