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Pediatric Questionnaire

This is the Pediatric Binocular Vision Dysfunction Questionnaire for ages 4-8.

If you think that your child has Binocular Vision Dysfunction, 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 child’s 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.

"*" indicates required fields

Child's Name*
Parent/Guardian's Name*

Directions

Children - answer these questions together with your Parent/Guardian. For every question, please answer YES or NO. If you wear glasses, answer the questions assuming that you are wearing them.
1. Does your child have difficulty reading or learning OR skip letters or words or lines OR misread words or reverse numbers or words OR lose their place often while reading?*
2. Does your child have poor handwriting – poor letter sizing (too big or too small), poor spacing, writing lines with an upward or downward slant?*
3. Does your child avoid near activities OR do they act out after 5-10 minutes if they must perform near activities?*
4. Does your child sit very close to the TV / monitor / electronic devices OR hold toys very close to their face to see them?*
5. Does your child have difficulty identifying shapes, colors, letters, numbers and common images that are age appropriate?*
6. Does your child walk with difficulty (do they sway, trip or fall OR bump into objects or people) OR avoid climbing on furniture or outdoor playscapes?*
7. Does your child have trouble seeing the board, or seeing up close?*
8. Does your child have difficulty catching or kicking a ball?*
9. Does your child have headaches or stomach aches at school, pre school or when away from home?*
10. Does your child have light sensitivity (closes/covers eyes in bright light) OR not like bright places?*
11. Does your child close or cover one eye when doing up close activities?*
12. Does your child have nervousness or anxiety OR get startled often OR is clingy in stores?*
13. Does your child squint or blink or make faces to see?*

Parent/Guardian: Has your child ever been diagnosed with

Learning Disability (LD)*
Dyslexia?*
Torticollis?*
Lazy eye?*
ADD/ADHD?*
Migraines or headache?*
Traumatic brain injury or concussion?*
Does your child blink his/her eyes a lot/much more than most children?*
Are your child’s verbal skills far ahead of his/her reading skills?*
Has your child ever had an eye operation?*

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

Rate each symptom from 0 -10 0 = None of that symptom 10 = Worst
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What Our Patients Are Saying

”Dr. Sonneberg and her staff are truly outstanding. She is a most experienced, capable and understanding optometrist. My eye exam for prism glasses was extremely thorough and her assistant Michelle picked out frames for me that were best suited for my needs. It was a great experience for me and it will be for you too. I highly recommend her.

Susan S.

”This was such an amazing experience. They made me feel comfortable and made sure I knew everything that was going on. Dr. Sonneberg was absolutely amazing and her staff were so great as well. I would highly recommend going to them with any eye issues you may be experiencing or related symptoms. She definitely changed my life.

McKenzie C.

”Exceptional experience from start to finish. All staff is extremely friendly and knowledgeable. Dr. Sonneberg is patient and kind. I am forever grateful for this team for helping me discover a diagnosis and treatment for my condition that has had me very sick for over 2 months. Highly recommend.

Sarah C.

”I can’t even put into words how validated & happy I feel today after visiting Dr. Sonneberg’s office. From the front staff, to the doctor, to the location everything was perfect. She makes you feel so comfortable and truly wants to get to the root cause of your issues and find you answers, no matter what. She is very thorough and honest to get you to the best you can be. I am so excited to finally be diagnosed with converge insufficiency & vertical heterophoria and am on my path to recovery. If you are having any uncomfortable vision issues, neck or shoulder pain, a head tilt, dizziness or anxiety you need to see her immediately. It’ll change your life I promise you that!

Sierra B.

”Dr. Sonneberg does a thorough examination. She is never satisfied until the refraction she prescribes is as good as it can be. She is patient and persistent in her efforts to help her patients.

Denise J.

”My experience here was very positive. The staff is all very friendly and accommodating. Dr. Sonneberg's exam was thorough. This was my first visit and she took the time to learn in detail about my vision history and specific vision problem. She made an excellent recommendation as far as further treatment I may require. I felt no pressure to spend any more than I'd planned and no service or product was "pushed" on me as a prior writer complained. I have no problem recommending this office to anyone.

UPDATE: It's been 5 years since I wrote this first visit review. Nothing I said then needs to be changed. I was there this morning and my visit could not have been pleasanter. I'd give 10 stars if I could.

Beth B.

”My son and I are new patients of Dr. Sonnenberg. After my initial visit with Dr. Sonnenberg, I had an emergency; I called her. She told me to come right over! She is very caring, compassionate, considerate, and warm. She took care of me right away. She is an amazing doctor! I can't imagine going to anyone else. Her office staff is friendly, courteous and knows their stuff! The office is relaxing; no rushing around! I will be a patient of Dr. Sonnenberg's forever! If you are looking for a good optometrist, she is the one to see. I travel from Coral Springs to see her. Thank you Dr. Sonnenberg and staff!

Penny D.

”Love this office!! Dr Sonneberg is so patient and friendly, and has really made a difference in my son's vision!! She is very thorough too! Her office staff is always smiling, having cute interactions with my kids, and very on the ball and organized. Best eye doctor we've ever been to!

Chani R.

”Dr. Sonneberg and her team are incredible! This was hands down the best experience I’ve ever had buying glasses and having my eyes checked. Deena and Dr. Sonneberg have amazing expertise in selecting frames and helped me pick ones that I never would have chosen, but are beyond perfect. And my eye exam with Dr. Sonneberg was very efficient and easy, and she took time to answer all of my questions and make sure I was comfortable with my contact lenses and glasses. I can't recommend Dr. Sonneberg’s office highly enough— a perfect experience.

Hadas A.

”I have been coming here for years and always have a great experience with Dr Sonneberg and the staff! They are very friendly and welcoming! Their attention to detail and the quality you get with your exam and fitting of glasses/contacts is the reason I keep coming back! Highly recommend!

Brett S.