Brain Injury Vision Symptom Survey

Brain Injury Vision Symptom Survey

Brain Injury Vision Symptom Survey

Brain Injury Vision Symptom Survey

BRAIN INJURY VISION SYMPTOM SURVEY

Patient Name

My brain injury was:( years ago )
My age is
DOB
Cause of injury

SYMPTOM CHECKLIST

Please check the most appropriate box, or circle the item number that best matches your observations. All information will be held in confidence. Thank you for your help!

Please rate each behavior

How often does each behavior occur?
EYESIGHT CLARITY
Distance vision blurred and not clear -- even with lenses
Near vision blurred and not clear -- even with lenses
Clarity of vision changes or fluctuates during the day
Poor night vision / can’t see well to drive at night
VISUAL COMFORT
Eye discomfort / sore eyes / eyestrain
Headaches or dizziness after using eyes
Eye fatigue / very tired after using eyes all day
Feel “pulling” around the eyes
DOUBLING
Double vision -- especially when tired
Have to close or cover one eye to see clearly
Print moves in and out of focus when reading
LIGHT SENSITIVITY
Normal indoor lighting is uncomfortable – too much glare
Outdoor light too bright – have to use sunglasses
Indoors fluorescent lighting is bothersome or annoying
DRY EYES
Eyes feel “dry” and sting
“Stare” into space without blinking
Have to rub the eyes a lot
DEPTH PERCEPTION
Clumsiness / misjudge where objects really are
Lack of confidence walking / missing steps / stumbling
Poor handwriting (spacing, size, legibility)
PERIPHERAL VISION
Side vision distorted / objects move or change position
What looks straight ahead--isn’t always straight ahead
Avoid crowds / can’t tolerate “visually-busy” places
READING
Short attention span / easily distracted when reading
Difficulty / slowness withreading and writing
Poor reading comprehension / can’t remember what was read
Confusion of words / skip words during reading
Lose place / have to use finger not to lose place when reading

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