Brain Injury Vision Symptom Survey (BIVSS) Name(Required) SelectMr.Mrs.MissMasterMxDr. Title First Last Pro NounsSelectHe/HimShe/HerThey/ThemAddress(Required)Today's Date(Required) Day Month Year Date of Birth(Required) Day Month Year 0 = Never 1 = Seldom 2 = Occasionally 3 = Frequently 4 = AlwaysA. Eyesight clarityDistance 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 behaviourHow often does each behaviour occur? (select 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 ComfortEye 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. DoublingDouble 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 SensitivityNormal 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 EyesEyes 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 PerceptionClumsiness / 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 VisionSide 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. ReadingShort 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 CAPTCHA Δ
