Name: City Optometry
Address: 530 Bush St #101, San Francisco, CA, 94108, US
Telephone: 415-291-8560
Price range: $000 - $300

Binocular Vision Questionnaire - Ages 15 and Over

This questionnaire is used by our practice for evaluation purposes. The results will be sent to our office, and we will contact you shortly after to review them with you.
Date
MM slash DD slash YYYY
Name*
First Last
Date of Birth*
MM slash DD slash YYYY
Email*
Phone (Main)*
Phone (Alternative - Optional)
Location*
City State
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
Frequently = At least 1 time / week
Occasionally = Less than 1 time / week
Never = Never
1. Do you have headaches and / or facial pain?*
- Always
- Frequently
- Occasionally
- Never
Describe location of discomfort on face or back of head:
Rate your discomfort on a scale from 1-10: 1=extremely mild, 10=extremely severe
2. Do you have pain in your eyes with eye movement?*
- Always
- Frequently
- Occasionally
- Never
3. Do you experience neck or shoulder discomfort?*
- Always
- Frequently
- Occasionally
- Never
4. Do you have dizziness and / or lightheadedness?*
- Always
- Frequently
- Occasionally
- Never
5. Do you experience dizziness, light-headedness, or nausea while performing close-up activities (i.e. - computer work, reading, writing)?*
- Always
- Frequently
- Occasionally
- Never
6. Do you experience dizziness, light-headedness, or nausea while performing far-distance activities (i.e. - driving, television, movies)?*
- Always
- Frequently
- Occasionally
- Never
7. 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
8. Do you feel unsteady with walking, or drift to one side while walking?*
- Always
- Frequently
- Occasionally
- Never
9. Do you feel overwhelmed or anxious while walking in a large department store (i.e. – Target, Costco, Malls)?*
- Always
- Frequently
- Occasionally
- Never
10. Do you feel overwhelmed or anxious when in a crowd?*
- Always
- Frequently
- Occasionally
- Never
11. Does riding in a car make you feel dizzy or uncomfortable?*
- Always
- Frequently
- Occasionally
- Never
12. Do you experience anxiety or nervousness because of your dizziness?*
- Always
- Frequently
- Occasionally
- Never
13. Do you ever find yourself with your head tilted to one side?*
- Always
- Frequently
- Occasionally
- Never
14. Do you experience poor depth perception or have difficulty estimating distances accurately?*
- Always
- Frequently
- Occasionally
- Never
15. Do you experience double/overlapping/shadowed vision at far distances?*
- Always
- Frequently
- Occasionally
- Never
16. Do you experience double/overlapping/shadowed vision at near distances?*
- Always
- Frequently
- Occasionally
- Never
17. Do you experience glare or have sensitivity to bright lights?*
- Always
- Frequently
- Occasionally
- Never
18. Do you close or cover one eye with near or far tasks?*
- Always
- Frequently
- Occasionally
- Never
19. 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)?*
- Always
- Frequently
- Occasionally
- Never
20. Do you tire easily with close-up tasks (computer work, reading, writing)?*
- Always
- Frequently
- Occasionally
- Never
21. Do you experience blurred vision with far-distance activities (i.e.-driving, television, movies, chalkboard at school)?*
- Always
- Frequently
- Occasionally
- Never
22. Do you experience blurred vision with close-up activities (i.e.- computer, reading, writing)?*
- Always
- Frequently
- Occasionally
- Never
23. 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)?*
- Always
- Frequently
- Occasionally
- Never
24. Do you experience words running together with reading?*
- Always
- Frequently
- Occasionally
- Never
25. Do you experience difficulty with reading or reading comprehension?*
- Always
- Frequently
- Occasionally
- Never
Traumatic brain injury or concussion?*
- Yes
- No
History of ear infections?*
- Yes
- No
Have you ever been diagnosed with a lazy eye?
- Yes
- No
Reading disability?*
- Yes
- No
Have you ever had an eye operation?*
- Yes
- No
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 =
Nausea =
Anxiety =
Headache =
Neckache =
Unsteady with walking =
Sensitivity to light =
Reading difficulty =
Please record any additional symptoms you may be experiencing or specific concerns that you have about your eyes / vision:
Tell us how you found us*
- Internet Search
- Referred by a friend
- Referred by a professional
- Found us in a forum, blog or social media
Please help us help others by using this box to be very specific about how you found us:*
Examples include:
•If you found us by Internet search, what key words did you use?
•If you were referred, who specifically referred you?
•If you found out about us on a blog or forum or social media site, specifically which one was it?
•Other: Please explain | Heard about us - where?

Take our pediatric binocular vision dysfunction questionnaire.

Schedule an Eye Exam

City Optometry

530 Bush St #101
San Francisco, CA 94108

Hours

Monday: 9:00 AM - 5:30 PM
Tuesday: 9:00 AM - 5:30 PM
Wednesday: 9:00 AM - 5:30 PM
Thursday: 9:00 AM - 5:30 PM
Friday: 9:30 AM - 5:30 PM
Saturday: Closed
Sunday: Closed

NOTE: On Saturdays, the doctor is available from 9:00 am - 2:30 pm. The Optical Boutique is open from 9:00 am - 4:00 pm.

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Binocular Vision Questionnaire - Ages 15 and Over

Directions:

City Optometry

Hours