Please note: This questionnaire is for those 13 years old or younger.
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.
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
Seldom = Less than 1 time / month
Occasionally = Less than 1 time / week
Frequently = At least 1 time / week
Always = Everyday
The Pattern Glare Test
The image with black and white stripes is called pattern glare. If it causes any negative symptoms such as headaches, strain, discomfort, or if the lines look like they are moving, it is a strong indicator that vision is provoking your symptoms.
If you find this image causes a high level of discomfort to the point that you cannot look at it, this can be an indicator of a visual problem.