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 vision Headache Blurred vision Pain in or around eyes Dizziness Vomiting Flashes of light Disorientation / fogginess Loss of balance Loss of memory Neck pain / whiplash Restricted field of view Restricted motion Loss of consciousness Coma
Total Checked:
Check any symptoms currently being experienced

Blurred Vision - Distance Blurred Vision - Near Eyes ache Pain in or around eyes Headaches Eye redness Watery eyes Pain with eye movement Eyes twitch Itchy eyes Difficult moving or turning eyes Difficulty changing focus far to near Motion sickness / car sickness Double vision Light sensitivity Objects moving in environment is bothersome Head moves when reading One eye turns in, out, up or down See overlapping or shadowed image Squinting, covering or closing one eye Lose place often when reading Words jump or move around when reading Short attention span reading or writing Skip words frequently when reading Discomfort when reading Have difficulty following moving targets Use a finger or an underliner when reading Orients writing /drawing poorly on page Hold books too close Avoid reading or writing Head tilts during desk work Difficulty with peripheral vision Flashes of light Objects jump in and out of field of view Reduced depth perception Tunnel vision / loss of visual field Trip or fall / poor balance Trouble seeing at night Often knock things over Bump into things, objects, chairs, or walls Clumsiness Difficulty with dressing Portions of objects /pages ever missing Startled by people or objects Dizziness Hold things, walls, people when walking Difficult bathing/personal hygiene Difficulty following series of directions Get lost often Confusion / disorientation Bothered by noises Difficulty remembering things seen Difficulty with numbers Difficulty using both sides of body together Difficulty remembering things heard Difficulty with time management Difficulty remembering name of objects Difficulty remembering people’s names Difficulty recalling info known in past Difficulty remembering former familiar people /objects Difficult performing tasks formerly easy /routine
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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