You can always press Enter⏎ to continue
BIVSS Symptom Checklist-Geelong
Hi there, please fill out and submit this form.
10
Questions
START
1
Name
First Name
Last Name
Previous
Next
Submit
Press
Enter
2
Eye Sight Clarity
How often do you CURRENTLY experience any of the following?
Never (0)
Seldom (1)
Occasionally (2)
Frequently (3)
Always (4)
Prior to Injury
Distance vision blurred - even with lenses
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
Row 0, Column 5
Near vision blurred - even with lenses
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Row 1, Column 4
Row 1, Column 5
Clarity of vision changes / fluctuates during the day
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Row 2, Column 4
Row 2, Column 5
Poor night vision
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
Row 3, Column 4
Row 3, Column 5
Distance vision blurred - even with lenses
Near vision blurred - even with lenses
Clarity of vision changes / fluctuates during the day
Poor night vision
Never (0)
Row 0, Column 0
Seldom (1)
Row 0, Column 1
Occasionally (2)
Row 0, Column 2
Frequently (3)
Row 0, Column 3
Always (4)
Row 0, Column 4
Prior to Injury
Row 0, Column 5
Never (0)
Row 1, Column 0
Seldom (1)
Row 1, Column 1
Occasionally (2)
Row 1, Column 2
Frequently (3)
Row 1, Column 3
Always (4)
Row 1, Column 4
Prior to Injury
Row 1, Column 5
Never (0)
Row 2, Column 0
Seldom (1)
Row 2, Column 1
Occasionally (2)
Row 2, Column 2
Frequently (3)
Row 2, Column 3
Always (4)
Row 2, Column 4
Prior to Injury
Row 2, Column 5
Never (0)
Row 3, Column 0
Seldom (1)
Row 3, Column 1
Occasionally (2)
Row 3, Column 2
Frequently (3)
Row 3, Column 3
Always (4)
Row 3, Column 4
Prior to Injury
Row 3, Column 5
1
of 4
Previous
Next
Submit
Press
Enter
3
Doubling
How often do you CURRENTLY experience any of the following?
Never (0)
Seldom (1)
Occasionally (2)
Frequently (3)
Always (4)
Prior to Injury
Double vision - especially when tired
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
Row 0, Column 5
Close or cover an eye to see clearly
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Row 1, Column 4
Row 1, Column 5
Print moves in and out of focus when reading
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Row 2, Column 4
Row 2, Column 5
Double vision - especially when tired
Close or cover an eye to see clearly
Print moves in and out of focus when reading
Never (0)
Row 0, Column 0
Seldom (1)
Row 0, Column 1
Occasionally (2)
Row 0, Column 2
Frequently (3)
Row 0, Column 3
Always (4)
Row 0, Column 4
Prior to Injury
Row 0, Column 5
Never (0)
Row 1, Column 0
Seldom (1)
Row 1, Column 1
Occasionally (2)
Row 1, Column 2
Frequently (3)
Row 1, Column 3
Always (4)
Row 1, Column 4
Prior to Injury
Row 1, Column 5
Never (0)
Row 2, Column 0
Seldom (1)
Row 2, Column 1
Occasionally (2)
Row 2, Column 2
Frequently (3)
Row 2, Column 3
Always (4)
Row 2, Column 4
Prior to Injury
Row 2, Column 5
1
of 3
Previous
Next
Submit
Press
Enter
4
Vision Comfort
How often do you CURRENTLY experience any of the following?
Never (0)
Seldom (1)
Occasionally (2)
Frequently (3)
Always (4)
Prior to Injury
Eye discomfort/sore eyes/eye strain
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
Row 0, Column 5
Headaches or dizziness after using eyes
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Row 1, Column 4
Row 1, Column 5
"Pulling" feeling around eyes
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Row 2, Column 4
Row 2, Column 5
Eye fatigue/tired after using eyes all day
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
Row 3, Column 4
Row 3, Column 5
Eye discomfort/sore eyes/eye strain
Headaches or dizziness after using eyes
"Pulling" feeling around eyes
Eye fatigue/tired after using eyes all day
Never (0)
Row 0, Column 0
Seldom (1)
Row 0, Column 1
Occasionally (2)
Row 0, Column 2
Frequently (3)
Row 0, Column 3
Always (4)
Row 0, Column 4
Prior to Injury
Row 0, Column 5
Never (0)
Row 1, Column 0
Seldom (1)
Row 1, Column 1
Occasionally (2)
Row 1, Column 2
Frequently (3)
Row 1, Column 3
Always (4)
Row 1, Column 4
Prior to Injury
Row 1, Column 5
Never (0)
Row 2, Column 0
Seldom (1)
Row 2, Column 1
Occasionally (2)
Row 2, Column 2
Frequently (3)
Row 2, Column 3
Always (4)
Row 2, Column 4
Prior to Injury
Row 2, Column 5
Never (0)
Row 3, Column 0
Seldom (1)
Row 3, Column 1
Occasionally (2)
Row 3, Column 2
Frequently (3)
Row 3, Column 3
Always (4)
Row 3, Column 4
Prior to Injury
Row 3, Column 5
1
of 4
Previous
Next
Submit
Press
Enter
5
Light Sensitivity
How often do you CURRENTLY experience any of the following?
Never (0)
Seldom (1)
Occasionally (2)
Frequently (3)
Always (4)
Prior to Injury
Normal indoor lighting is uncomfortable - too much glare
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
Row 0, Column 5
Outdoor lighting is too bright - must use sunglasses
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Row 1, Column 4
Row 1, Column 5
Fluorescent lighting is bothersome / annoying
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Row 2, Column 4
Row 2, Column 5
Normal indoor lighting is uncomfortable - too much glare
Outdoor lighting is too bright - must use sunglasses
Fluorescent lighting is bothersome / annoying
Never (0)
Row 0, Column 0
Seldom (1)
Row 0, Column 1
Occasionally (2)
Row 0, Column 2
Frequently (3)
Row 0, Column 3
Always (4)
Row 0, Column 4
Prior to Injury
Row 0, Column 5
Never (0)
Row 1, Column 0
Seldom (1)
Row 1, Column 1
Occasionally (2)
Row 1, Column 2
Frequently (3)
Row 1, Column 3
Always (4)
Row 1, Column 4
Prior to Injury
Row 1, Column 5
Never (0)
Row 2, Column 0
Seldom (1)
Row 2, Column 1
Occasionally (2)
Row 2, Column 2
Frequently (3)
Row 2, Column 3
Always (4)
Row 2, Column 4
Prior to Injury
Row 2, Column 5
1
of 3
Previous
Next
Submit
Press
Enter
6
Dry Eyes
How often do you CURRENTLY experience any of the following?
Never (0)
Seldom (1)
Occasionally (2)
Frequently (3)
Always (4)
Prior to Injury
Eyes feel 'dry' and sting
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
Row 0, Column 5
"Stare" into space without blinking
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Row 1, Column 4
Row 1, Column 5
Rub eyes a lot
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Row 2, Column 4
Row 2, Column 5
Eyes feel 'dry' and sting
"Stare" into space without blinking
Rub eyes a lot
Never (0)
Row 0, Column 0
Seldom (1)
Row 0, Column 1
Occasionally (2)
Row 0, Column 2
Frequently (3)
Row 0, Column 3
Always (4)
Row 0, Column 4
Prior to Injury
Row 0, Column 5
Never (0)
Row 1, Column 0
Seldom (1)
Row 1, Column 1
Occasionally (2)
Row 1, Column 2
Frequently (3)
Row 1, Column 3
Always (4)
Row 1, Column 4
Prior to Injury
Row 1, Column 5
Never (0)
Row 2, Column 0
Seldom (1)
Row 2, Column 1
Occasionally (2)
Row 2, Column 2
Frequently (3)
Row 2, Column 3
Always (4)
Row 2, Column 4
Prior to Injury
Row 2, Column 5
1
of 3
Previous
Next
Submit
Press
Enter
7
Depth Perception
How often do you CURRENTLY experience any of the following?
Never (0)
Seldom (1)
Occasionally (2)
Frequently (3)
Always (4)
Prior to Injury
Clumsiness / Misjudge where objects really are
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
Row 0, Column 5
Lack of confidence walking / missing steps / stumbling
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Row 1, Column 4
Row 1, Column 5
Poor handwriting (spacing, sizing, legibility)
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Row 2, Column 4
Row 2, Column 5
Clumsiness / Misjudge where objects really are
Lack of confidence walking / missing steps / stumbling
Poor handwriting (spacing, sizing, legibility)
Never (0)
Row 0, Column 0
Seldom (1)
Row 0, Column 1
Occasionally (2)
Row 0, Column 2
Frequently (3)
Row 0, Column 3
Always (4)
Row 0, Column 4
Prior to Injury
Row 0, Column 5
Never (0)
Row 1, Column 0
Seldom (1)
Row 1, Column 1
Occasionally (2)
Row 1, Column 2
Frequently (3)
Row 1, Column 3
Always (4)
Row 1, Column 4
Prior to Injury
Row 1, Column 5
Never (0)
Row 2, Column 0
Seldom (1)
Row 2, Column 1
Occasionally (2)
Row 2, Column 2
Frequently (3)
Row 2, Column 3
Always (4)
Row 2, Column 4
Prior to Injury
Row 2, Column 5
1
of 3
Previous
Next
Submit
Press
Enter
8
Peripheral Vision
How often do you CURRENTLY experience any of the following?
Never (0)
Seldom (1)
Occasionally (2)
Frequently (3)
Always (4)
Prior to Injury
Avoid crowds / Can't tolerate "visually-busy" places
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
Row 0, Column 5
What looks straight ahead is not always straight ahead
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Row 1, Column 4
Row 1, Column 5
Side vision distorted / Objects move or change position
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Row 2, Column 4
Row 2, Column 5
Avoid crowds / Can't tolerate "visually-busy" places
What looks straight ahead is not always straight ahead
Side vision distorted / Objects move or change position
Never (0)
Row 0, Column 0
Seldom (1)
Row 0, Column 1
Occasionally (2)
Row 0, Column 2
Frequently (3)
Row 0, Column 3
Always (4)
Row 0, Column 4
Prior to Injury
Row 0, Column 5
Never (0)
Row 1, Column 0
Seldom (1)
Row 1, Column 1
Occasionally (2)
Row 1, Column 2
Frequently (3)
Row 1, Column 3
Always (4)
Row 1, Column 4
Prior to Injury
Row 1, Column 5
Never (0)
Row 2, Column 0
Seldom (1)
Row 2, Column 1
Occasionally (2)
Row 2, Column 2
Frequently (3)
Row 2, Column 3
Always (4)
Row 2, Column 4
Prior to Injury
Row 2, Column 5
1
of 3
Previous
Next
Submit
Press
Enter
9
Reading
How often do you CURRENTLY experience any of the following?
Never (0)
Seldom (1)
Occasionally (2)
Frequently (3)
Always (4)
Prior to Injury
Short attention span / easily distracted when reading
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
Row 0, Column 5
Difficulty / Slowed reading or writing
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Row 1, Column 4
Row 1, Column 5
Poor comprehension / cannot recall what was read
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Row 2, Column 4
Row 2, Column 5
Confusion of words / skip words while reading
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
Row 3, Column 4
Row 3, Column 5
Loss of place / use finger to keep place when reading
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Row 4, Column 3
Row 4, Column 4
Row 4, Column 5
Short attention span / easily distracted when reading
Difficulty / Slowed reading or writing
Poor comprehension / cannot recall what was read
Confusion of words / skip words while reading
Loss of place / use finger to keep place when reading
Never (0)
Row 0, Column 0
Seldom (1)
Row 0, Column 1
Occasionally (2)
Row 0, Column 2
Frequently (3)
Row 0, Column 3
Always (4)
Row 0, Column 4
Prior to Injury
Row 0, Column 5
Never (0)
Row 1, Column 0
Seldom (1)
Row 1, Column 1
Occasionally (2)
Row 1, Column 2
Frequently (3)
Row 1, Column 3
Always (4)
Row 1, Column 4
Prior to Injury
Row 1, Column 5
Never (0)
Row 2, Column 0
Seldom (1)
Row 2, Column 1
Occasionally (2)
Row 2, Column 2
Frequently (3)
Row 2, Column 3
Always (4)
Row 2, Column 4
Prior to Injury
Row 2, Column 5
Never (0)
Row 3, Column 0
Seldom (1)
Row 3, Column 1
Occasionally (2)
Row 3, Column 2
Frequently (3)
Row 3, Column 3
Always (4)
Row 3, Column 4
Prior to Injury
Row 3, Column 5
Never (0)
Row 4, Column 0
Seldom (1)
Row 4, Column 1
Occasionally (2)
Row 4, Column 2
Frequently (3)
Row 4, Column 3
Always (4)
Row 4, Column 4
Prior to Injury
Row 4, Column 5
1
of 5
Previous
Next
Submit
Press
Enter
10
Do you experience any of the following?
Never (0)
Seldom (1)
Occassionally (2)
Frequently (3)
Always (4)
Prior to Injury
Difficulty changing focus or sustaining focus
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
Row 0, Column 5
Bothered by noise
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Row 1, Column 4
Row 1, Column 5
Motion sickness/car sickness
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Row 2, Column 4
Row 2, Column 5
Awkward/poor balance
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
Row 3, Column 4
Row 3, Column 5
Difficulty recalling
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Row 4, Column 3
Row 4, Column 4
Row 4, Column 5
Difficulty with time management
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Row 5, Column 3
Row 5, Column 4
Row 5, Column 5
Difficulty changing focus or sustaining focus
Bothered by noise
Motion sickness/car sickness
Awkward/poor balance
Difficulty recalling
Difficulty with time management
Never (0)
Row 0, Column 0
Seldom (1)
Row 0, Column 1
Occassionally (2)
Row 0, Column 2
Frequently (3)
Row 0, Column 3
Always (4)
Row 0, Column 4
Prior to Injury
Row 0, Column 5
Never (0)
Row 1, Column 0
Seldom (1)
Row 1, Column 1
Occassionally (2)
Row 1, Column 2
Frequently (3)
Row 1, Column 3
Always (4)
Row 1, Column 4
Prior to Injury
Row 1, Column 5
Never (0)
Row 2, Column 0
Seldom (1)
Row 2, Column 1
Occassionally (2)
Row 2, Column 2
Frequently (3)
Row 2, Column 3
Always (4)
Row 2, Column 4
Prior to Injury
Row 2, Column 5
Never (0)
Row 3, Column 0
Seldom (1)
Row 3, Column 1
Occassionally (2)
Row 3, Column 2
Frequently (3)
Row 3, Column 3
Always (4)
Row 3, Column 4
Prior to Injury
Row 3, Column 5
Never (0)
Row 4, Column 0
Seldom (1)
Row 4, Column 1
Occassionally (2)
Row 4, Column 2
Frequently (3)
Row 4, Column 3
Always (4)
Row 4, Column 4
Prior to Injury
Row 4, Column 5
Never (0)
Row 5, Column 0
Seldom (1)
Row 5, Column 1
Occassionally (2)
Row 5, Column 2
Frequently (3)
Row 5, Column 3
Always (4)
Row 5, Column 4
Prior to Injury
Row 5, Column 5
1
of 6
Previous
Next
Submit
Press
Enter
Should be Empty:
Question Label
1
of
10
See All
Go Back
Submit
