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Practice Name

Heights Eye Center

Primary Location
227 1/2 Boulevard
Hasbrouck Heights, NJ 07604
Phone: 201-288-1109
Fax: 201-288-1589

Office Hours

DayMorningAfternoon
Monday9:30 AM - 6:00 PM
Tuesday11:00 AM - 7:00 PM
Wednesday9:30 AM - 2:30 PM
Thursday9:30 AM - 7:00 PM
Friday8:30 AM - 4:00 PM
SaturdayBy Appt.
SundayClosed
Main Content

Is it my eyes?

Binocular Vision Dysfunction Questionnaire

Welcome! You’re probably on this page for one or more of the following:

• you have experienced symptoms such as headaches, blurry vision, dizziness, or anxiety over a short or extended period of time

• you have seen one or more specialists for your symptoms and nothing seems to help

• you have experienced a concussion or traumatic brain injury (TBI)

• you have been diagnosed with ADHD, dyslexia, other learning disabilities

• you were asked by a friend to “just take the test”

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.

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 the best interpretation of the results.

Never

Occasionally - Less than 1 time / week

Frequently - At least 1 time / week

Always - Everyday

On an average day, how much are you bothered by the 8 symptoms listed below?

Rate each symptom from 0 to 10, with 10 as the worst it could be, and with 0 meaning you have none of that symptom

Have you ever been diagnosed with:

If you want to tell us more about your symptoms, or if you have specific questions, share them here:

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 a social media site, specifically which one was it?

• Other: please explain. Heard about us - where?

Sign-up using the form or call us at 201-288-1109 to take advantage of this exclusive offer.

Name: *
Email: *
Phone: *


Now Offering Retinal Scanning with...

Online Forms

Heights Eye Center offers our patient form(s) online so they can be completed in the convenience of your own home or office.
Download Online Forms Here

  

Request Appointment

We will do our best to accommodate your busy schedule. Request an appointment today!

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Services

We strive to provide complete care for our patients. Learn more about all the services we provide.

Read More

Heights Eye Center
227 1/2 Boulevard
Hasbrouck Heights, NJ 07604
Get Directions
 
  • Phone: 201-288-1109
  • Fax: 201-288-1589
  • Email Us

Office Hours

DayMorningAfternoon
Monday9:30 AM - 6:00 PM
Tuesday11:00 AM - 7:00 PM
Wednesday9:30 AM - 2:30 PM
Thursday9:30 AM - 7:00 PM
Friday8:30 AM - 4:00 PM
SaturdayBy Appt.
SundayClosed
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