798 Nicholson St
Fitzroy North, Victoria 3068
Phone :
03 9481 3381
Book an appointment
798 Nicholson St
Fitzroy North, Victoria 3068
03 9481 3381
Book an appointment
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Home
Brain Injury
Brain Injury Vision Symptom Survey (BIVSS)
Name*
Address*
Today's Date*
Date Of Birth*
0 = Never
1 = Seldom
2 = Occasionally
3 = Frequently
4 = Always
A.
Eyesight clarity
Distance vision blurred and not clear - even with lenses
0
1
2
3
4
Near vision blurred and not clear - even with lenses
0
1
2
3
4
B.
Please rate each behaviour
How often does each behaviour occur? (circle a number)
Clarity of vision changes or fluctuates during the day
0
1
2
3
4
Poor night vision / can't see well to drive at night
0
1
2
3
4
C.
Visual Comfort
Eye discomfort / sore eyes / eyestrain
0
1
2
3
4
Headaches or dizziness after using eyes
0
1
2
3
4
Eye fatigue / very tired after using eyes all day
0
1
2
3
4
Feel "pulling" around the eyes
0
1
2
3
4
D.
Doubling
Double vision - especially when tired
0
1
2
3
4
Have to close one eye to see clearly?
0
1
2
3
4
Print moves in and out of focus when reading
0
1
2
3
4
E.
Light Sensitivity
Normal indoor lighting is uncomfortable - too much glare
0
1
2
3
4
Outdoor light too bright - have to use sunglasses
0
1
2
3
4
Indoor fluorescent lighting is bothersome or annoying
0
1
2
3
4
F.
Dry Eyes
Eyes feel "dry" and sting
0
1
2
3
4
"Stare" into space without blinking
0
1
2
3
4
Have to rub eyes a lot
0
1
2
3
4
G.
Depth Percecption
Clumsiness / misjudge where objects really are
0
1
2
3
4
Lack of confidence walking / missing steps / stumbling
0
1
2
3
4
Poor handwriting (spacing, size, legibility)
0
1
2
3
4
H.
Peripheral Vision
Side vision distorted / objects move or change position
0
1
2
3
4
What looks straight ahead - isn't always straight ahead
0
1
2
3
4
Avoid crowds / can't tolerate "visually-busy" places
0
1
2
3
4
I.
Reading
Short attention span / easily distracted when reading
0
1
2
3
4
Difficulty / slowness with reading and writing
0
1
2
3
4
Poor reading comprehension / can't remember what was read
0
1
2
3
4
Confusion of words / skip words during reading
0
1
2
3
4
Lose place / have to use finger not to lost place when reading
0
1
2
3
4
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