Brain Injury Vision Symptom Survey

Brain Injury Vision Symptom Survey
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!

Dr. Saleel Jivraj BSc (Hons) OD MBA FAAO FEAOO FCOptom FBCLA FIACLE FIALVS
Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
My brain/head concussion injury was (date)blanks* Years ago.
My age isblank* Years.
Cause of Concussion/Injury/MVA: blanks*
Today's Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
SYMPTOM CHECKLIST

Please rate each behavior. How often does each behavior occur? (circle a number)

EYESIGHT CLARITY:

Rows	Never	Seldom	Occasionally	Frequently	Always
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:

Rows	Never	Seldom	Occasionally	Frequently	Always
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:

Rows	Never	Seldom	Occasionally	Frequently	Always
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:

Rows	Never	Seldom	Occasionally	Frequently	Always
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:

Rows	Never	Seldom	Occasionally	Frequently	Always
Eyes feel “dry” and sting
“Stare” into space without blinking
Have to rub the eyes a lot

DEPTH PERCEPTION:

Rows	Never	Seldom	Occasionally	Frequently	Always
Clumsiness / misjudge where objects really are
Lack of confidence walking / missing steps / stumbling
Poor handwriting (spacing, size, legibility)

PERIPHERAL VISION:

Rows	Never	Seldom	Occasionally	Frequently	Always
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:

Rows	Never	Seldom	Occasionally	Frequently	Always
Short attention span / easily distracted when reading
Difficulty / slowness with reading 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

SYMPTOM CHECKLIST