BIVSS Checklist
(Brain Injury Vision Symptom Survey)
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Birth
*
-
Month
-
Day
Year
Date
Todays Date
*
-
Month
-
Day
Year
Date
Please rate each behavior.
How often does each behavior occur? (select an option)
Eyesight Clarity
Distance vision blurred and not clear - even with lenses
Never
1
2
3
4
Always
5
1 is Never, 5 is Always
Near vision blurred and not clear - even with lenses
Never
1
2
3
4
Always
5
1 is Never, 5 is Always
Clarity of vision changes or fluctuates during the day
Never
1
2
3
4
Always
5
1 is Never, 5 is Always
Poor night vision / can't see well to drive at night
Never
1
2
3
4
Always
5
1 is Never, 5 is Always
Visual Comfort
Eye discomfort / sore eyes / eyestrain
Never
1
2
3
4
Always
5
1 is Never, 5 is Always
Headaches or dizziness after using eyes
Never
1
2
3
4
Always
5
1 is Never, 5 is Always
Eye fatigue / very tired after using eyes all day
Never
1
2
3
4
Always
5
1 is Never, 5 is Always
Feel "pulling" around the eyes
Never
1
2
3
4
Always
5
1 is Never, 5 is Always
Doubling
Double vision - especially when tired
Never
1
2
3
4
Always
5
1 is Never, 5 is Always
Have to close or cover one eye to see clearly
Never
1
2
3
4
Always
5
1 is Never, 5 is Always
Print moves in and out of focus when reading
Never
1
2
3
4
Always
5
1 is Never, 5 is Always
Light Sensitivity
Normal indoor lighting is uncomfortable - too much glare
Never
1
2
3
4
Always
5
1 is Never, 5 is Always
Outdoor light too bright - have to use sunglasses
Never
1
2
3
4
Always
5
1 is Never, 5 is Always
Indoors fluorescent lighting is bothersome or annoying
Never
1
2
3
4
Always
5
1 is Never, 5 is Always
Dry Eyes
Eyes feel "dry" and sting
Never
1
2
3
4
Always
5
1 is Never, 5 is Always
"Stare" into space without blinking
Never
1
2
3
4
Always
5
1 is Never, 5 is Always
Have to rub the eyes a lot
Never
1
2
3
4
Always
5
1 is Never, 5 is Always
Depth Perception
Clumsiness / misjudge where objects really are
Never
1
2
3
4
Always
5
1 is Never, 5 is Always
Lack of confidence walking / missing steps / stumbling
Never
1
2
3
4
Always
5
1 is Never, 5 is Always
Poor handwriting (spacing, size, legibility)
Never
1
2
3
4
Always
5
1 is Never, 5 is Always
Peripheral Vision
Side vision distorted / objects move or change positions
Never
1
2
3
4
Always
5
1 is Never, 5 is Always
What looks straight ahead - isn't always straight ahead
Never
1
2
3
4
Always
5
1 is Never, 5 is Always
Avoids crowds / can't tolerate "visually busy" places
Never
1
2
3
4
Always
5
1 is Never, 5 is Always
Reading
Short attention span / easily distracted when reading
Never
1
2
3
4
Always
5
1 is Never, 5 is Always
Difficulty / slowness with reading and writing
Never
1
2
3
4
Always
5
1 is Never, 5 is Always
Poor reading comprehension / can't remember what was read
Never
1
2
3
4
Always
5
1 is Never, 5 is Always
Confusion of words / skips words during reading
Never
1
2
3
4
Always
5
1 is Never, 5 is Always
Loses place / have to use finger not to lose place when reading
Never
1
2
3
4
Always
5
1 is Never, 5 is Always
Would you like our office to contact you to schedule an appointment?
*
Yes
No
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