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BIVSS Symptom Checklist-Geelong
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10
Questions
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1
Name
First Name
Last Name
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2
Eye Sight Clarity
How often do you CURRENTLY experience any of the following?
Prior to Injury
Never (0)
Seldom (1)
Occassionally (2)
Frequently (3)
Always (4)
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
Prior to Injury
Row 0, Column 0
Never (0)
Row 0, Column 1
Seldom (1)
Row 0, Column 2
Occassionally (2)
Row 0, Column 3
Frequently (3)
Row 0, Column 4
Always (4)
Row 0, Column 5
Prior to Injury
Row 1, Column 0
Never (0)
Row 1, Column 1
Seldom (1)
Row 1, Column 2
Occassionally (2)
Row 1, Column 3
Frequently (3)
Row 1, Column 4
Always (4)
Row 1, Column 5
Prior to Injury
Row 2, Column 0
Never (0)
Row 2, Column 1
Seldom (1)
Row 2, Column 2
Occassionally (2)
Row 2, Column 3
Frequently (3)
Row 2, Column 4
Always (4)
Row 2, Column 5
Prior to Injury
Row 3, Column 0
Never (0)
Row 3, Column 1
Seldom (1)
Row 3, Column 2
Occassionally (2)
Row 3, Column 3
Frequently (3)
Row 3, Column 4
Always (4)
Row 3, Column 5
1
of 4
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3
Eye Teaming/Binocular Vision
How often do you CURRENTLY experience any of the following?
Never (0)
Seldom (1)
Occassionally (2)
Frequently (3)
Always (4)
Prior to Injury
Double vision
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 covers 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
Close or covers 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
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
1
of 3
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4
Vision Comfort
How often do you CURRENTLY experience any of the following?
Never (0)
Seldom (1)
Occassionally (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
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
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
1
of 4
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5
Light Sensitivity
How often do you CURRENTLY experience any of the following?
Prior to Injury
Never (0)
Seldom (1)
Occassionally (2)
Frequently (3)
Always (4)
Normal indoor lighting is uncomfortable/glary
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
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/glary
Outdoor lighting is too bright-must use sunglasses
Fluorescent lighting is bothersome
Prior to Injury
Row 0, Column 0
Never (0)
Row 0, Column 1
Seldom (1)
Row 0, Column 2
Occassionally (2)
Row 0, Column 3
Frequently (3)
Row 0, Column 4
Always (4)
Row 0, Column 5
Prior to Injury
Row 1, Column 0
Never (0)
Row 1, Column 1
Seldom (1)
Row 1, Column 2
Occassionally (2)
Row 1, Column 3
Frequently (3)
Row 1, Column 4
Always (4)
Row 1, Column 5
Prior to Injury
Row 2, Column 0
Never (0)
Row 2, Column 1
Seldom (1)
Row 2, Column 2
Occassionally (2)
Row 2, Column 3
Frequently (3)
Row 2, Column 4
Always (4)
Row 2, Column 5
1
of 3
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6
Dry Eyes
How often do you CURRENTLY experience any of the following?
Prior to Injury
Never (0)
Seldom (1)
Occassionally (2)
Frequently (3)
Always (4)
Eyes feel 'dry'/scratchy/ 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'/scratchy/ sting
"Stare" into space without blinking
Rub eyes a lot
Prior to Injury
Row 0, Column 0
Never (0)
Row 0, Column 1
Seldom (1)
Row 0, Column 2
Occassionally (2)
Row 0, Column 3
Frequently (3)
Row 0, Column 4
Always (4)
Row 0, Column 5
Prior to Injury
Row 1, Column 0
Never (0)
Row 1, Column 1
Seldom (1)
Row 1, Column 2
Occassionally (2)
Row 1, Column 3
Frequently (3)
Row 1, Column 4
Always (4)
Row 1, Column 5
Prior to Injury
Row 2, Column 0
Never (0)
Row 2, Column 1
Seldom (1)
Row 2, Column 2
Occassionally (2)
Row 2, Column 3
Frequently (3)
Row 2, Column 4
Always (4)
Row 2, Column 5
1
of 3
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7
Depth Perception
How often do you CURRENTLY experience any of the following?
Never (0)
Seldom (1)
Occassionally (2)
Frequently (3)
Always (4)
Prior to Injury
Misjudge where objects really are/ clumsiness
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
Misjudge where objects really are/ clumsiness
Lack of confidence walking/ missing steps/ stumbling
Poor handwriting (spacing, sizing, legibility)
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
1
of 3
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8
Peripheral Vision
How often do you CURRENTLY experience any of the following?
Prior to Injury
Never (0)
Seldom (1)
Occassionally (2)
Frequently (3)
Always (4)
Avoid crowds/cannot tolerate 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 different/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/cannot tolerate busy places
What looks straight ahead is not always straight ahead
Side vision different/objects move or change position
Prior to Injury
Row 0, Column 0
Never (0)
Row 0, Column 1
Seldom (1)
Row 0, Column 2
Occassionally (2)
Row 0, Column 3
Frequently (3)
Row 0, Column 4
Always (4)
Row 0, Column 5
Prior to Injury
Row 1, Column 0
Never (0)
Row 1, Column 1
Seldom (1)
Row 1, Column 2
Occassionally (2)
Row 1, Column 3
Frequently (3)
Row 1, Column 4
Always (4)
Row 1, Column 5
Prior to Injury
Row 2, Column 0
Never (0)
Row 2, Column 1
Seldom (1)
Row 2, Column 2
Occassionally (2)
Row 2, Column 3
Frequently (3)
Row 2, Column 4
Always (4)
Row 2, Column 5
1
of 3
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9
Reading
How often do you CURRENTLY experience any of the following?
Prior to Injury
Never (0)
Seldom (1)
Occassionally (2)
Frequently (3)
Always (4)
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
Prior to Injury
Row 0, Column 0
Never (0)
Row 0, Column 1
Seldom (1)
Row 0, Column 2
Occassionally (2)
Row 0, Column 3
Frequently (3)
Row 0, Column 4
Always (4)
Row 0, Column 5
Prior to Injury
Row 1, Column 0
Never (0)
Row 1, Column 1
Seldom (1)
Row 1, Column 2
Occassionally (2)
Row 1, Column 3
Frequently (3)
Row 1, Column 4
Always (4)
Row 1, Column 5
Prior to Injury
Row 2, Column 0
Never (0)
Row 2, Column 1
Seldom (1)
Row 2, Column 2
Occassionally (2)
Row 2, Column 3
Frequently (3)
Row 2, Column 4
Always (4)
Row 2, Column 5
Prior to Injury
Row 3, Column 0
Never (0)
Row 3, Column 1
Seldom (1)
Row 3, Column 2
Occassionally (2)
Row 3, Column 3
Frequently (3)
Row 3, Column 4
Always (4)
Row 3, Column 5
Prior to Injury
Row 4, Column 0
Never (0)
Row 4, Column 1
Seldom (1)
Row 4, Column 2
Occassionally (2)
Row 4, Column 3
Frequently (3)
Row 4, Column 4
Always (4)
Row 4, Column 5
1
of 5
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10
How often do you CURRENTLY experience any of the following?
Never (0)
Seldom (1)
Occassionally (2)
Frequently (3)
Always (4)
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
Bothered by noise
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Row 1, Column 4
Motion sickness/car sickness
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Row 2, Column 4
Awkward/poor balance
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
Row 3, Column 4
Difficulty recalling
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Row 4, Column 3
Row 4, Column 4
Difficulty with time management
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Row 5, Column 3
Row 5, Column 4
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
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
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
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
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
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
1
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