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Home » Patient Symptom Surveys » Brain Injury/Visual Survey

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

  • NeverSeldomOccasionallyFrequentlyAlways
  • NeverSeldomOccasionallyFrequentlyAlways
  • NeverSeldomOccasionallyFrequentlyAlways
  • NeverSeldomOccasionallyFrequentlyAlways
  • VISUAL COMFORT

  • NeverSeldomOccasionallyFrequentlyAlways
  • NeverSeldomOccasionallyFrequentlyAlways
  • NeverSeldomOccasionallyFrequentlyAlways
  • NeverSeldomOccasionallyFrequentlyAlways
  • DOUBLING

  • NeverSeldomOccasionallyFrequentlyAlways
  • NeverSeldomOccasionallyFrequentlyAlways
  • NeverSeldomOccasionallyFrequentlyAlways
  • LIGHT SENSITIVITY

  • NeverSeldomOccasionallyFrequentlyAlways
  • NeverSeldomOccasionallyFrequentlyAlways
  • NeverSeldomOccasionallyFrequentlyAlways
  • DRY EYES

  • NeverSeldomOccasionallyFrequentlyAlways
  • NeverSeldomOccasionallyFrequentlyAlways
  • NeverSeldomOccasionallyFrequentlyAlways
  • DEPTH PERCEPTION

  • NeverSeldomOccasionallyFrequentlyAlways
  • NeverSeldomOccasionallyFrequentlyAlways
  • NeverSeldomOccasionallyFrequentlyAlways
  • PERIPHERAL VISION

  • NeverSeldomOccasionallyFrequentlyAlways
  • NeverSeldomOccasionallyFrequentlyAlways
  • NeverSeldomOccasionallyFrequentlyAlways
  • READING

  • NeverSeldomOccasionallyFrequentlyAlways
  • NeverSeldomOccasionallyFrequentlyAlways
  • NeverSeldomOccasionallyFrequentlyAlways
  • NeverSeldomOccasionallyFrequentlyAlways
  • NeverSeldomOccasionallyFrequentlyAlways