Brain Injury/Visual Survey

Patient Name
First Last
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
Never Seldom Occasionally Frequently Always
Near vision blurred and not clear-even with lenses
Never Seldom Occasionally Frequently Always
Clarity of vision changes or fluctuates during the day
Never Seldom Occasionally Frequently Always
Poor night vision/can't see well to drive at night
Never Seldom Occasionally Frequently Always
VISUAL COMFORT
Eye discomfort/sore eyes/eyestrain
Never Seldom Occasionally Frequently Always
Headaches or dizziness after using eyes
Never Seldom Occasionally Frequently Always
Eye fatigue/very tired after using eyes all day
Never Seldom Occasionally Frequently Always
Feel "pulling" around the eyes
Never Seldom Occasionally Frequently Always
DOUBLING
Double vision-especially when tired
Never Seldom Occasionally Frequently Always
Have to close or cover one eye to see clearly
Never Seldom Occasionally Frequently Always
Print moves in and out of focus when reading
Never Seldom Occasionally Frequently Always
LIGHT SENSITIVITY
Normal indoor lighting is uncomfortable-too much glare
Never Seldom Occasionally Frequently Always
Outdoor light is too bright-have to use sunglasses
Never Seldom Occasionally Frequently Always
Poor handwriting (spacing, sizing, legibility)
Never Seldom Occasionally Frequently Always
DRY EYES
Eyes feel "dry" and sting
Never Seldom Occasionally Frequently Always
Stare into space without blinking
Never Seldom Occasionally Frequently Always
Have to rub the eyes a lot
Never Seldom Occasionally Frequently Always
DEPTH PERCEPTION
Clumsiness/misjudge where objects really are
Never Seldom Occasionally Frequently Always
Lack of confidence-walking/missing steps/stumbling
Never Seldom Occasionally Frequently Always
Poor handwriting (spacing, sizing, legibility)
Never Seldom Occasionally Frequently Always
PERIPHERAL VISION
Side vision distorted/objects move or change position
Never Seldom Occasionally Frequently Always
What looks straight ahead isn't always straight ahead
Never Seldom Occasionally Frequently Always
Avoid crowds/can't tolerate "visually-busy" places
Never Seldom Occasionally Frequently Always
READING
Short attention span/easily distracted when reading
Never Seldom Occasionally Frequently Always
Difficulty/slowness with reading and writing
Never Seldom Occasionally Frequently Always
Poor reading comprehension/can't remember what was read
Never Seldom Occasionally Frequently Always
Confusion of words/skip words during reading
Never Seldom Occasionally Frequently Always
Lose place/have to use finger to not lose place when reading
Never Seldom Occasionally Frequently Always

EYESIGHT CLARITY

VISUAL COMFORT

DOUBLING

LIGHT SENSITIVITY

DRY EYES

DEPTH PERCEPTION

PERIPHERAL VISION

READING

Superior Eye Health & Vision Therapy Center