Have you or your child ever experienced a traumatic brain injury (ie: concussion, stroke, etc.) ?
YES
NO
BIVSS : Brain Injury Vision Symptom
My brain injury was
(NUMBER)
years ago.
Select all that apply:
Cause of injury:
How often do the following behaviors occur?
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
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
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
Normal indoor lighting is uncomfortable - too much glare.
Never
1
2
3
4
Always
5
1 is Never , 5 is Always
Outdoor light is too bright - have to use sunglasses.
Never
1
2
3
4
Always
5
1 is Never , 5 is Always
Indoor florescent lighting is bothersome or annoying.
Never
1
2
3
4
Always
5
1 is Never , 5 is Always
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 eyes a lot.
Never
1
2
3
4
Always
5
1 is Never , 5 is Always
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
Side vision distorted / objects move or change position.
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
Avoid crowds / can't tolerate "visually-busy" places.
Never
1
2
3
4
Always
5
1 is Never , 5 is Always
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 / skip words during reading.
Never
1
2
3
4
Always
5
1 is Never , 5 is Always
Lost place / have to use finger not to lose place when reading.
Never
1
2
3
4
Always
5
1 is Never , 5 is Always
Your BIVSS Score:
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Binocular Vision Dysfunction : Screening
How often do you or your child experience the following symptoms?
Headaches during or after near work (ie: reading, writing, drawing, knitting, etc.)
Never
1
2
3
4
Always
5
1 is Never , 5 is Always
Omitting small words (ie: a, the, it, he) when reading.
Never
1
2
3
4
Always
5
1 is Never , 5 is Always
Words or letters melding together and/or moving while reading.
Never
1
2
3
4
Always
5
1 is Never , 5 is Always
Skipping and/or repeating lines while reading.
Never
1
2
3
4
Always
5
1 is Never , 5 is Always
Using a finger, ruler, or other implement to read.
Never
1
2
3
4
Always
5
1 is Never , 5 is Always
Difficulty copying from a chalkboard, computer, or whiteboard.
Never
1
2
3
4
Always
5
1 is Never , 5 is Always
Writing that slants (uphill or downhill), or runs off the lines and/or page.
Never
1
2
3
4
Always
5
1 is Never , 5 is Always
Misaligning columns of numbers, letters, or objects.
Never
1
2
3
4
Always
5
1 is Never , 5 is Always
Poor reading comprehension; having to read the same sentence/paragraph multiple times to understand the content.
Never
1
2
3
4
Always
5
1 is Never , 5 is Always
Burning, itchy, or watery eyes.
Never
1
2
3
4
Always
5
1 is Never , 5 is Always
Tilting head or closing one eye when reading or doing everyday tasks.
Never
1
2
3
4
Always
5
1 is Never , 5 is Always
Clumsiness, bumping into things frequently, and knocking things over.
Never
1
2
3
4
Always
5
1 is Never , 5 is Always
Neck strain after reading, writing, computer work, etc.
Never
1
2
3
4
Always
5
1 is Never , 5 is Always
Holding books or near work very close to your face/eyes.
Never
1
2
3
4
Always
5
1 is Never , 5 is Always
Avoiding or disliking near work, reading, or writing.
Never
1
2
3
4
Always
5
1 is Never , 5 is Always
Short attention span with near work.
Never
1
2
3
4
Always
5
1 is Never , 5 is Always
Feeling or saying "I can't" before trying something.
Never
1
2
3
4
Always
5
1 is Never , 5 is Always
Poor time management or use of time. Unable to create a schedule or routine and/or difficulty completing assignments or tasks on time.
Never
1
2
3
4
Always
5
1 is Never , 5 is Always
Losing belongings or misplacing things.
Never
1
2
3
4
Always
5
1 is Never , 5 is Always
Forgetting things.
Never
1
2
3
4
Always
5
1 is Never , 5 is Always
Binocular Vision Score:
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Your BIVSS Score:
Your Binocular Vision Score:
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Interested in Scheduling an Assessment?
Complete the next page to receive a phone call from one of our vision therapy team, and book your appointment today.
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GENERAL / HEALTH INFORMATION
Have you had a routine eye exam within the last 12 months?
*
YES
NO
NO - but have one scheduled in the next 3 weeks
Have your symptoms impacted your ability to work or attend school ?
*
YES
NO
If YES, please specify :
Have your symptoms impacted your ability to perform tasks of daily life ?
*
YES
NO
If YES, please specify :
Are you currently, or have you recently, participated in rehabilitative therapy for your symptoms ? (ie: physio therapy, speech therapy, occupational therapy)
*
YES
NO
If YES, please specify :
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PATIENT INFORMATION
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*
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*
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