BIVSS Survey

My brain injury was: (Please indicate a year ago)

Age:

Zip Code

Please check the most appropriate box, or circle the item number that best matches your observations. All information will be held in confidence. Thank you for your help!

SYMPTOM CHECKLIST

Please rate each behavior

• 0 = Never

• 1 = Seldom

• 2 = Occasionally

• 3 = Frequently

• 4 = Always

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 too bright – have to use sunglasses

Indoors fluorescent lighting is bothersome or annoying

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, size, 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 not to lose place when reading