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TBI-Visual Symptoms Questionnaire

  • Please consider each symptom and rate the presence of symptoms by marking 0 if the symptom is not present, 1 if the symptom is /rarely present, 2 if the symptom is occasionally present, or 3 if the symptom is frequently present.

  • 012
    Emergent Visual Conditions
    Flashes of light
    Floaters in field of view
    Restricted field of vision
    "Curtains" billowing into field of view
  • 012
    Urgent Visual Conditions
    Inability to completely close eyes
    Difficulty moving or turning eyes
    Pain with movement of the eyes
    Pain in or around eyes
    Wandering eye
    Double vision
  • 012
    TBI/ABI Optometric Vision Rehabilitation Conditions
    Blurred vision for distance viewing
    Blurred vision for near viewing
    Slow shift of focus from near to far to near
    Difficulty copying or taking notes
    Pulling or tugging sensation around eyes
    Discomfort/eyestrain while reading
    General fatigue while work/reading
    Unable to sustain near work or reading for periods of time
    Eyes get tired while reading
    Covering, closing one eye
    Headaches while reading
    Loss of place while reading
    Missing a portion of their vision
    Bumping into objects or not seeing objects on one side more so than the other
    Easily distracted when reading
    Slower speed of reading
    Decreased attention span
    Reduced concentration ability
    Difficulty remembering what has been read
  • 012
    Loss of balance
    Poor posture
    Face, head turn or head tilt
    Bothered by movement in environment
    Bothered by crowded environments
    Light sensitivity
    A sensation of the floor, ceiling or walls tilting
    A sensation of the room spinning
    A sensation of not feeling grounded
    Postural shifts/ veering off when walking

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