You can always press Enter⏎ to continue
Chevy Chase Eyecare – Youth BVDQ Intake
HIPAA
Compliance
1
Part 1: Symptoms
Directions: Children - answer these questions together with your Parents. For every question, select 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
Previous
Next
Submit
Press
Enter
2
Do you have headaches or stomach aches or do you get nervous/anxious at school?
*
This field is required.
Always
Frequently
Occasionally
Never
Previous
Next
Submit
Press
Enter
3
While reading or watching video in a car, do you get a headache or stomach ache or feel unwell?
*
This field is required.
Always
Frequently
Occasionally
Never
Previous
Next
Submit
Press
Enter
4
Do you get sick to your stomach or nauseous on swings or circular rides?
*
This field is required.
Always
Frequently
Occasionally
Never
Previous
Next
Submit
Press
Enter
5
Do you have difficulty playing sports, or doing gymnastics or dance?
*
This field is required.
Always
Frequently
Occasionally
Never
Previous
Next
Submit
Press
Enter
6
Do you have trouble catching baseballs or footballs or Frisbees?
*
This field is required.
Always
Frequently
Occasionally
Never
Previous
Next
Submit
Press
Enter
7
When you are walking, do you bump into people or furniture or door frames?
*
This field is required.
Always
Frequently
Occasionally
Never
Previous
Next
Submit
Press
Enter
8
Are you anxious or nervous?
*
This field is required.
Always
Frequently
Occasionally
Never
Previous
Next
Submit
Press
Enter
9
Does it take you a long time to finish your homework?
*
This field is required.
Always
Frequently
Occasionally
Never
Previous
Next
Submit
Press
Enter
10
Do you have to read the same thing a couple of times to really understand it?
*
This field is required.
Always
Frequently
Occasionally
Never
Previous
Next
Submit
Press
Enter
11
When reading, do you skip lines or lose your place OR do you use a guide (finger, ruler or a piece of paper) to help you keep your place?
*
This field is required.
Always
Frequently
Occasionally
Never
Previous
Next
Submit
Press
Enter
12
When you read, does it look like the letters are moving OR does it seem like words are bumping into each other?
*
This field is required.
Always
Frequently
Occasionally
Never
Previous
Next
Submit
Press
Enter
13
Do bright lights hurt your eyes?
*
This field is required.
Always
Frequently
Occasionally
Never
Previous
Next
Submit
Press
Enter
14
Do you close or cover one eye to make it easier to see?
*
This field is required.
Always
Frequently
Occasionally
Never
Previous
Next
Submit
Press
Enter
15
Do you ever see two of everything (double vision)?
*
This field is required.
Always
Frequently
Occasionally
Never
Previous
Next
Submit
Press
Enter
16
When reading or working on the computer or electronic device, do your eyes feel tired or does your vision get blurry?
*
This field is required.
Always
Frequently
Occasionally
Never
Previous
Next
Submit
Press
Enter
17
When looking at the blackboard at school, do your eyes feel tired or does your vision get blurry?
*
This field is required.
Always
Frequently
Occasionally
Never
Previous
Next
Submit
Press
Enter
18
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)
Previous
Next
Submit
Press
Enter
19
Dizziness
*
This field is required.
10 is the worst it could be, and 0 means you have none of that symptom
0
1
2
3
4
5
6
7
8
9
10
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
Row 0, Column 5
Row 0, Column 6
Row 0, Column 7
Row 0, Column 8
Row 0, Column 9
Row 0, Column 10
0
1
2
3
4
5
6
7
8
9
10
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
Row 0, Column 5
Row 0, Column 6
Row 0, Column 7
Row 0, Column 8
Row 0, Column 9
Row 0, Column 10
Previous
Next
Submit
Press
Enter
20
Nausea
*
This field is required.
10 is the worst it could be, and 0 means you have none of that symptom
0
1
2
3
4
5
6
7
8
9
10
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
Row 0, Column 5
Row 0, Column 6
Row 0, Column 7
Row 0, Column 8
Row 0, Column 9
Row 0, Column 10
0
1
2
3
4
5
6
7
8
9
10
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
Row 0, Column 5
Row 0, Column 6
Row 0, Column 7
Row 0, Column 8
Row 0, Column 9
Row 0, Column 10
Previous
Next
Submit
Press
Enter
21
Anxiety
*
This field is required.
10 is the worst it could be, and 0 means you have none of that symptom
0
1
2
3
4
5
6
7
8
9
10
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
Row 0, Column 5
Row 0, Column 6
Row 0, Column 7
Row 0, Column 8
Row 0, Column 9
Row 0, Column 10
0
1
2
3
4
5
6
7
8
9
10
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
Row 0, Column 5
Row 0, Column 6
Row 0, Column 7
Row 0, Column 8
Row 0, Column 9
Row 0, Column 10
Previous
Next
Submit
Press
Enter
22
Headache
*
This field is required.
10 is the worst it could be, and 0 means you have none of that symptom
0
1
2
3
4
5
6
7
8
9
10
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
Row 0, Column 5
Row 0, Column 6
Row 0, Column 7
Row 0, Column 8
Row 0, Column 9
Row 0, Column 10
0
1
2
3
4
5
6
7
8
9
10
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
Row 0, Column 5
Row 0, Column 6
Row 0, Column 7
Row 0, Column 8
Row 0, Column 9
Row 0, Column 10
Previous
Next
Submit
Press
Enter
23
Neckache
*
This field is required.
10 is the worst it could be, and 0 means you have none of that symptom
0
1
2
3
4
5
6
7
8
9
10
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
Row 0, Column 5
Row 0, Column 6
Row 0, Column 7
Row 0, Column 8
Row 0, Column 9
Row 0, Column 10
0
1
2
3
4
5
6
7
8
9
10
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
Row 0, Column 5
Row 0, Column 6
Row 0, Column 7
Row 0, Column 8
Row 0, Column 9
Row 0, Column 10
Previous
Next
Submit
Press
Enter
24
Unsteady with Walking
*
This field is required.
10 is the worst it could be, and 0 means you have none of that symptom
0
1
2
3
4
5
6
7
8
9
10
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
Row 0, Column 5
Row 0, Column 6
Row 0, Column 7
Row 0, Column 8
Row 0, Column 9
Row 0, Column 10
0
1
2
3
4
5
6
7
8
9
10
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
Row 0, Column 5
Row 0, Column 6
Row 0, Column 7
Row 0, Column 8
Row 0, Column 9
Row 0, Column 10
Previous
Next
Submit
Press
Enter
25
Sensitivity to Light
*
This field is required.
10 is the worst it could be, and 0 means you have none of that symptom
0
1
2
3
4
5
6
7
8
9
10
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
Row 0, Column 5
Row 0, Column 6
Row 0, Column 7
Row 0, Column 8
Row 0, Column 9
Row 0, Column 10
0
1
2
3
4
5
6
7
8
9
10
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
Row 0, Column 5
Row 0, Column 6
Row 0, Column 7
Row 0, Column 8
Row 0, Column 9
Row 0, Column 10
Previous
Next
Submit
Press
Enter
26
Reading Difficulty
*
This field is required.
10 is the worst it could be, and 0 means you have none of that symptom
0
1
2
3
4
5
6
7
8
9
10
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
Row 0, Column 5
Row 0, Column 6
Row 0, Column 7
Row 0, Column 8
Row 0, Column 9
Row 0, Column 10
0
1
2
3
4
5
6
7
8
9
10
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
Row 0, Column 5
Row 0, Column 6
Row 0, Column 7
Row 0, Column 8
Row 0, Column 9
Row 0, Column 10
Previous
Next
Submit
Press
Enter
27
Part 3: Previous Diagnosis
Have you ever been diagnosed with...
Previous
Next
Submit
Press
Enter
28
Learning Disability (LD)
*
This field is required.
YES
NO
Previous
Next
Submit
Press
Enter
29
Dyslexia?
*
This field is required.
YES
NO
Previous
Next
Submit
Press
Enter
30
Torticollis?
*
This field is required.
YES
NO
Previous
Next
Submit
Press
Enter
31
Lazy eye?
*
This field is required.
YES
NO
Previous
Next
Submit
Press
Enter
32
ADD / ADHD?
*
This field is required.
YES
NO
Previous
Next
Submit
Press
Enter
33
Migraines or headache?
*
This field is required.
YES
NO
Previous
Next
Submit
Press
Enter
34
Traumatic brain injury or concussion?
*
This field is required.
Have you experienced or been diagnosed with either?
YES
NO
Previous
Next
Submit
Press
Enter
35
Does your child blink their eyes a lot / much more than most children?
*
This field is required.
YES
NO
Previous
Next
Submit
Press
Enter
36
Are your child’s verbal skills far ahead of their reading skills?
*
This field is required.
YES
NO
Previous
Next
Submit
Press
Enter
37
Has your child ever had an eye operation?
*
This field is required.
YES
NO
Previous
Next
Submit
Press
Enter
38
Comment Section
If you want to tell us more about your 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.
Huge
Large
Normal
Small
Ok
quote
Created with Sketch.
Ok
Previous
Next
Submit
Press
Enter
39
Name
*
This field is required.
First Name
Last Name
Previous
Next
Submit
Press
Enter
40
Age
*
This field is required.
Previous
Next
Submit
Press
Enter
41
Calculation
Previous
Next
Submit
Press
Enter
Should be Empty:
Question Label
1
of
41
See All
Go Back
Submit