My brain/head concussion injury was (date)blanks* Years ago. My age isblank* Years.
Cause of Concussion/Injury/MVA: blanks*
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
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
Double vision -- especially when tired
Have to close or cover one eye to see clearly
Print moves in and out of focus when reading
Normal indoor lighting is uncomfortable – too much glare
Outdoor light too bright – have to use sunglasses
Indoors fluorescent lighting is bothersome or annoying
Eyes feel “dry” and sting
“Stare” into space without blinking
Have to rub the eyes a lot
Clumsiness / misjudge where objects really are
Lack of confidence walking / missing steps / stumbling
Poor handwriting (spacing, size, legibility)
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
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