BIVSS CHECKLIST (Brain Injury Vision Symptom Survey) Patient Name: First Last Today’s date: MM slash DD slash YYYY My brain injury was:(years ago)My age is:( years) I have had a medical diagnosis of brain injury (check box if true)Cause of injury: I sustained a brain injury without medical diagnosis (check box if true) I have NOT ever sustained a brain injury (check box if true)Please check the most appropriate option that best matches your observations. All information will be held in confidence. Thank you for your help! Please rate each behavior. How often does each behavior occur?EYESIGHT CLARITYDistance 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 COMFORTEye 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 DOUBLINGDouble 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 SENSITIVITYNormal indoor lighting is uncomfortable – too much glare Never Seldom Occasionally Frequently Always Outdoor light too bright – have to use sunglasses Never Seldom Occasionally Frequently Always Indoors fluorescent lighting is bothersome or annoying Never Seldom Occasionally Frequently Always DRY EYESEyes 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 PERCEPTIONClumsiness / 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, size, legibility) Never Seldom Occasionally Frequently Always PERIPHERAL VISIONSide 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 READINGShort 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 not to lose place when reading Never Seldom Occasionally Frequently Always This field is hidden when viewing the formtotal score for all 28-items: Δ
