Brain Injury/Visual Survey


INSTRUCTIONS:
Please check the most appropriate box that best matches your symptoms today.
Please rate each symptom. How often does each occur?

EYESIGHT CLARITY

Distance vision blurred and not clear-even with lenses

Near vision blurred and not clear-even with lenses

Clarity of vision changes or fluctuates during the day

Poor night vision/can't see well to drive at night


VISUAL COMFORT

Eye discomfort/sore eyes/eyestrain

Headaches or dizziness after using eyes

Eye fatigue/very tired after using eyes all day

Feel "pulling" around the eyes


DOUBLING

Double vision-especially when tired

Have to close or cover one eye to see clearly

Print moves in and out of focus when reading


LIGHT SENSITIVITY

Normal indoor lighting is uncomfortable-too much glare

Outdoor light is too bright-have to use sunglasses

Poor handwriting (spacing, sizing, legibility)


DRY EYES

Eyes feel "dry" and sting

Stare into space without blinking

Have to rub the eyes a lot


DEPTH PERCEPTION

Clumsiness/misjudge where objects really are

Lack of confidence-walking/missing steps/stumbling

Poor handwriting (spacing, sizing, legibility)


PERIPHERAL VISION

Side vision distorted/objects move or change position

What looks straight ahead isn't always straight ahead

Avoid crowds/can't tolerate "visually-busy" places


READING

Short attention span/easily distracted when reading

Difficulty/slowness with reading and writing

Poor reading comprehension/can't remember what was read

Confusion of words/skip words during reading

Lose place/have to use finger to not lose place when reading