Pediatric Binocular Vision Dysfunction Questionnaire (P-BVDQ) for children 17 years old and younger

Family Eyecare Center 7500 Ramble Way Suite 101 Raleigh, NC 27616 (919) 981-4444

Name

Age

Email Address

Phone Number

Directions: Children - answer these questions together with your Parents. For every question, 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
Occasionally - Less than 1 time/week
Frequently - At least 1 time/week
Always - Everyday

Do you have headaches or face pain?

Never

Occasionally

Frequently

Always

Do your eyes hurt and/or does it hurt to move your eyes?

Never

Occasionally

Frequently

Always

Do you have neck pain or a stiff neck or upper back pain?

Never

Occasionally

Frequently

Always

Do you have stomach aches or nausea?

Never

Occasionally

Frequently

Always

Do you get car sickness or motion sickness?

Never

Occasionally

Frequently

Always

Did you get sick in the car seat when you were a small child?

Never

Occasionally

Frequently

Always

Do you get sick to your stomach or nauseous on swings or circular rides?

Never

Occasionally

Frequently

Always

Does riding in the car give you headaches or stomach aches?

Never

Occasionally

Frequently

Always

Do you have trouble reading in the car?

Never

Occasionally

Frequently

Always

Do you feel clumsy or klutzy or uncoordinated?

Never

Occasionally

Frequently

Always

When you are walking, do you bump into people or furniture or door frames?

Never

Occasionally

Frequently

Always

Do you feel funny or dizzy when you bend over and stand back up quickly?

Never

Occasionally

Frequently

Always

Are you anxious or nervous?

Never

Occasionally

Frequently

Always

In grocery stores or malls, do you stay close (cling) to your Mom or Dad? (Do you feel uncomfortable in grocery stores or malls?)

Never

Occasionally

Frequently

Always

Do you tend to play alone or with just a few other kids? (Do you tend to play apart from the main group of kids?)

Never

Occasionally

Frequently

Always

Is reading hard for you or are you a slow reader?

Never

Occasionally

Frequently

Always

Do you have to read the same thing a couple of times to really understand it?

Never

Occasionally

Frequently

Always

Do you use your finger or a ruler or a piece of paper to help you keep your place when you are reading?

Never

Occasionally

Frequently

Always

Do you skip lines or lose your place when you are reading? *

Never

Occasionally

Frequently

Always

When you read, does it look like the letters are moving OR does it seem like words are bumping into each other?

Never

Occasionally

Frequently

Always

Do bright lights hurt your eyes?

Never

Occasionally

Frequently

Always

Do you close or cover one eye to make it easier to see?

Never

Occasionally

Frequently

Always

Do you have trouble catching baseballs or footballs or Frisbees?

Never

Occasionally

Frequently

Always

Do you ever see two of everything (double vision)?

Never

Occasionally

Frequently

Always

Is it hard for you to watch 3-D movies?

Never

Occasionally

Frequently

Always

When reading or working on the computer, do your eyes feel tired or does your vision get blurry?

Never

Occasionally

Frequently

Always

When looking at the blackboard at school, do your eyes feel tired or does your vision get blurry?

Never

Occasionally

Frequently

Always

Mom / Dad: Has your child ever been diagnosed with:

Learning disability (LD)?

Yes

No

Dyslexia?

Yes

No

Torticollis?

Yes

No

Lazy eye?

Yes

No

Reading disability?

Yes

No

ADD / ADHD?

Yes

No

Migraines or headache disorder?

Yes

No

Traumatic brain injury or concussion?

Yed

No

Does your child blink their eyes a lot / much more then most children?

Yes

No

Are your child’s verbal skills far ahead of their reading skills?

Yes

No

Has your child ever had an eye operation?

Yes

No

On a average day, how much are you bothered by the 8 symptoms below? (Rate each symptom from 0 to 10, where 10 is the worst it could be, and 0 means you do not experience that symptom.

Dizziness

Nausea

Anxiety

Headache

Neckache

Unsteady While Walking

Sensitivity to Light

Reading Difficulty

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