Concussion Survey

Concussion Survey

We are experienced in treating vision deficiencies and other visual disturbances caused by Traumatic Brain Injury (concussion). If you or your child has been diagnosed and continues to have symptoms, vision therapy, prisms or other treatments may be recommended.
A recent study at Children’s Hospital of Philadelphia showed 50% of adolescents after concussion had problems with eye teaming, focusing or tracking that made returning to school or sports more difficult.

Fortunately, many visual problems after concussion will resolve over time with rest and allowing the brain to heal. When visual symptoms persist, even if other symptoms such as dizziness or poor balance have resolved, visual therapy, also referred to as neuro-optometric rehabilitation, can be very effective.

The survey below may assist the doctor in developing the best plan for treatment. Check the box to the left of each question that best describes your answer. You may print the form or submit your information to our office upon scheduling an appointment for a post-concussion consultation.

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Check any symptoms experienced immediately following the accident or injury

Double visionHeadacheBlurred visionPain in or around eyesDizzinessVomitingFlashes of lightDisorientation / fogginessLoss of balanceLoss of memoryNeck pain / whiplashRestricted field of viewRestricted motionLoss of consciousnessComaOther
Total Checked:
Check any symptoms currently being experienced

Blurred Vision - DistanceBlurred Vision - NearEyes achePain in or around eyesHeadachesEye rednessWatery eyesPain with eye movementEyes twitchItchy eyesDifficult moving or turning eyesDifficulty changing focus far to nearMotion sickness / car sicknessDouble visionLight sensitivityObjects moving in environment is bothersomeHead moves when readingOne eye turns in, out, up or downSee overlapping or shadowed imageSquinting, covering or closing one eyeLose place often when readingWords jump or move around when readingShort attention span reading or writingSkip words frequently when readingDiscomfort when readingHave difficulty following moving targetsUse a finger or an underliner when readingOrients writing /drawing poorly on pageHold books too closeAvoid reading or writingHead tilts during desk workDifficulty with peripheral visionFlashes of lightObjects jump in and out of field of viewReduced depth perceptionTunnel vision / loss of visual fieldTrip or fall / poor balanceTrouble seeing at nightOften knock things overBump into things, objects, chairs, or wallsClumsinessDifficulty with dressingPortions of objects /pages ever missingStartled by people or objectsDizzinessHold things, walls, people when walkingDifficult bathing/personal hygieneDifficulty following series of directionsGet lost oftenConfusion / disorientationBothered by noisesDifficulty remembering things seenDifficulty with numbersDifficulty using both sides of body togetherDifficulty remembering things heardDifficulty with time managementDifficulty remembering name of objectsDifficulty remembering people’s namesDifficulty recalling info known in pastDifficulty remembering former familiar people /objectsDifficult performing tasks formerly easy /routineOther
Total Checked:
Answers may be printed for your records by clicking the "Print" button below.
You may also fill in your contact details below and hit the "Submit to our Office" button to forward your information to us in preparation for your next appointment. To schedule an appointment online, click here, or call our office at 212.410.1291
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