BIVSS Initial and Final Visit

Welcome to your BIVSS Initial and Final Visit

Below you will fill out the Brain Injury Vision Symptom Survey.
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I will only ask you to do this survey on your first and final physical therapy visit to track overall progress.
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This questionnaire will take approximately 3-5minutes and is important for measuring your progress!
Please remember to go back to your email with the links and complete ALL 3 QUESTIONNAIRES

1. 
Distance vision blurred and not clear - even with lenses

2. 
Near vision blurred and not clear - even with lenses

3. 
Clarity of vision changes or fluctuates during the day

4. 
Poor night vision / can't see well to drive at night

5. 
Eye discomfort / sore eyes / eye strain

6. 
Headaches or dizziness after using eyes

7. 
Eye fatigue / very tired after using eyes all day

8. 
Feel "pulling" around the eyes

9. 
Double vision - especially when tired

10. 
Have to close or cover one eye to see clearly

11. 
Print moves in and out of focus when reading

12. 
Normal indoor lighting is uncomfortable - too much glare

13. 
Outdoor light too bright - have to use sunglasses

14. 
Indoors fluorescent lighting is bothersome or annoying

15. 
Eyes feel "dry" and sting

16. 
"Stare" into space without blinking

17. 
Have to rub the eyes a lot

18. 
Clumsiness / misjudge where objects really are

19. 
Lack of confidence walking / missing steps / stumbling

20. 
Poor handwriting (spacing, size, legibility)

21. 
Side vision (peripheral vision) distorted / objects move or change position

22. 
What looks straight ahead isn't always straight ahead

23. 
Avoid crowds / can't tolerate "visually-busy" places

24. 
Short attention span / easily distracted when reading

25. 
Difficulty / slowness with reading and writing

26. 
Poor reading comprehension / can't remember what was read

27. 
Confusion of words / skip words during reading

28. 
Lose place / have to use finger not to lose place when reading

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