If you think that you might have Vertical Heterophoria, please fill out this Questionnaire and send it to us after it is completed. We will interpret your responses and contact you regarding the results.

If you would like to tell us more about your symptoms, please write about them in the Comment Section at the end of the Questionnaire. We will combine this information with the responses you gave in the Questionnaire to provide you with a more detailed interpretation of the results.
 
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Your Age:  
Over 17 years old?  Click Here
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Email Address: Today's Date: 5/20/2012
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

1. Do you have headaches or face pain?  
2. Do your eyes hurt and/or does it hurt to move your eyes?   
3. Do you have neck pain or a stiff neck or upper back pain?   
4. Do you have stomach aches or nausea?   
5. Do you get car sickness or motion sickness?   
6. Did you get sick in the car seat when you were a small child?   
7. Do you get sick to your stomach or nauseous on swings or circular rides?   
8. Does riding in the car give you headaches or stomach aches?   
9. Do you have trouble reading in the car?   
10. Do you feel clumsy or klutzy or uncoordinated?   
11. When you are walking, do you bump into people or furniture or door frames?   
12. Do you feel funny or dizzy when you bend over and stand back up quickly?   
13. Are you anxious or nervous?   
14. In grocery stores or malls, do you stay close (cling) to your Mom or Dad? (Do you feel uncomfortable in grocery stores or malls?)   
15. 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?)   
16. Is reading hard for you or are you a slow reader?  
17. Do you have to read the same thing a couple of times to really understand it?   
18. Do you use your finger or a ruler or a piece of paper to help you keep your place when you are reading?   
19. Do you skip lines or lose your place when you are reading?  
20. When you read, does it look like letters are moving or does it seem like words are bumping into each other?   
21. Do bright lights hurt your eyes?   
22. Do you close or cover one eye to make it easier to see?   
23. Do you have trouble catching baseballs or footballs or frisbees?   
24. Do you ever see two of everything (double vision)?   
25. Is it hard for you to watch 3-D movies?   
26. When reading or working on the computer, do your eyes feel tired or does your vision get blurry?   
27. When looking at the blackboard at school, do your eyes feel tired or does your vision get blurry?   
Mom / Dad: Has your child ever been diagnosed with:
Learning disability (LD)?   Reading disability?  
Dyslexia?   ADD / ADHD?  
Torticollis?   Migraines or headache disorder?  
Lazy Eye?   Traumatic brain injury or concussion?  
Does your child blink their eyes a lot / much more than most children?  
Are your child's verbal skills far ahead of their reading skills?  
Has your child ever had an eye operation?  


Comment Section: If you want to tell us more about you symptoms, or if you have specific questions, record them here:

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