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Chevy Chase Eyecare – Adult BVDQ Intake

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    Part 1: Symptoms 

    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

     

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    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)

     

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    10 is the worst it could be, and 0 means you have none of that symptom
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    10 is the worst it could be, and 0 means you have none of that symptom
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    10 is the worst it could be, and 0 means you have none of that symptom
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    10 is the worst it could be, and 0 means you have none of that symptom
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    10 is the worst it could be, and 0 means you have none of that symptom
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    10 is the worst it could be, and 0 means you have none of that symptom
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    10 is the worst it could be, and 0 means you have none of that symptom
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    10 is the worst it could be, and 0 means you have none of that symptom
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    Part 3: History

    Have you ever been diagnosed with...

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    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.
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