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

Do you have headaches and / or facial pain?* This field is required.

Always

Frequently

Occasionally

Never

Do you have pain in your eyes with eye movement?* This field is required.

Always

Frequently

Occasionally

Never

Do you experience neck or shoulder discomfort?* This field is required.

Always

Frequently

Occasionally

Never

Do you have dizziness and / or lightheadedness?* This field is required.

Always

Frequently

Occasionally

Never

Do you experience dizziness, light-headedness, or nausea while performing close-up activities (i.e. - computer work, reading, writing)?* This field is required.

Always

Frequently

Occasionally

Never

Do you experience dizziness, light-headedness, or nausea while performing far-distance activities (i.e. - driving, television, movies)?* This field is required.

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?* This field is required.

Always

Frequently

Occasionally

Never

Do you feel unsteady with walking, or drift to one side while walking?* This field is required.

Always

Frequently

Occasionally

Never

Do you feel overwhelmed or anxious while walking in a large department store (i.e. – Target, Wal-Mart, etc.)?* This field is required.

Always

Frequently

Occasionally

Never

Do you feel overwhelmed or anxious when in a crowd?* This field is required.

Always

Frequently

Occasionally

Never

Does riding in a car make you feel dizzy or uncomfortable?* This field is required.

Always

Frequently

Occasionally

Never

Do you experience anxiety or nervousness because of your dizziness?* This field is required.

Always

Frequently

Occasionally

Never

Do you ever find yourself with your head tilted to one side?* This field is required.

Always

Frequently

Occasionally

Never

Do you experience poor depth perception or have difficulty estimating distances accurately?* This field is required.

Always

Frequently

Occasionally

Never

Do you experience double / overlapping / shadowed vision at far distances?* This field is required.

Always

Frequently

Occasionally

Never

Do you experience double / overlapping / shadowed vision at near distances?* This field is required.

Always

Frequently

Occasionally

Never

Do you experience glare or have sensitivity to bright lights?* This field is required.

Always

Frequently

Occasionally

Never

Do you close or cover one eye with near or far tasks?* This field is required.

Always

Frequently

Occasionally

Never

Do you skip lines or lose your place while reading (do you use your finger or a ruler or other guides to maintain your position on the page)?* This field is required.

Always

Frequently

Occasionally

Never

Do you tire easily with close-up tasks (computer work, reading, writing)?* This field is required.

Always

Frequently

Occasionally

Never

Do you experience blurred vision with far-distance activities (i.e. - driving, television, movies, chalkboard at school)?* This field is required.

Always

Frequently

Occasionally

Never

Do you experience blurred vision with close-up activities (i.e. - computer work, reading, writing)?* This field is required.

Always

Frequently

Occasionally

Never

Do you blink to clear up distant objects after working at a desk or working with close-up activities (i.e. - computer work, reading, writing)?* This field is required.

Always

Frequently

Occasionally

Never

Do you experience words running together with reading?* This field is required.

Always

Frequently

Occasionally

Never

Do you experience difficulty with reading or reading comprehension?* This field is required.

Always

Frequently

Occasionally

Never

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)

Dizziness* This field is required.10 is the worst it could be, and 0 means you have none of that symptom

Nausea* This field is required.10 is the worst it could be, and 0 means you have none of that symptom

Anxiety* This field is required.10 is the worst it could be, and 0 means you have none of that symptom

Headaches* This field is required.10 is the worst it could be, and 0 means you have none of that symptom

Neckache* This field is required.10 is the worst it could be, and 0 means you have none of that symptom

Unsteady with Walking* This field is required.10 is the worst it could be, and 0 means you have none of that symptom

Sensitivity to Light* This field is required.10 is the worst it could be, and 0 means you have none of that symptom

Reading Difficulty* This field is required.10 is the worst it could be, and 0 means you have none of that symptom

Part 3: History

Have you ever been diagnosed with...

Traumatic Brain Injury* This field is required.

Yes

Reading Disability* This field is required.

Yes

Lazy Eye* This field is required.

Yes

Have you ever had an eye operation?* This field is required.

Yes

Comment Section* This field is required.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.

How did you find us?* This field is required.

Internet Search

Referred by a Friend

Referred by a Professional

Found us in a forum, blog, or social media

Facebook

Other

Name* This field is required.

First Name

Last Name

Age* This field is required.

Email* This field is required.

example@example.com

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

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)

Part 3: History

Have you ever been diagnosed with...

Never = Never
Occasionally = Less than 1 time / week
Frequently = At least 1 time / week
Always = Everyday