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Just north of the intersection of Woodruff Rd. and S. Highway 14 in Greenville, SC

Home » Protected: Special Assessment Forms » POST-TRAUMA VISION SYNDROME – Symptom Checklist

POST-TRAUMA VISION SYNDROME – Symptom Checklist

  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY

  • Please check frequency of each symptom:

  • EYESIGHT CLARITY

  • Please check frequency of each symptom, and if applicable, use the last column to indicate if the symptom existed before your injury

  • Never10%20%30%40%50%60%70%80%90%Always-Pre-existing Symptom
  • Never10%20%30%40%50%60%70%80%90%Always
  • Never10%20%30%40%50%60%70%80%90%Always
  • Never10%20%30%40%50%60%70%80%90%Always
  • VISUAL COMFORT

  • Never10%20%30%40%50%60%70%80%90%Always
  • Never10%20%30%40%50%60%70%80%90%Always
  • Never10%20%30%40%50%60%70%80%90%Always
  • PHYSICAL COMFORT / BEHAVIORS

  • Never10%20%30%40%50%60%70%80%90%Always
  • Never10%20%30%40%50%60%70%80%90%Always
  • Never10%20%30%40%50%60%70%80%90%Always
  • Never10%20%30%40%50%60%70%80%90%Always
  • Never10%20%30%40%50%60%70%80%90%Always
  • Never10%20%30%40%50%60%70%80%90%Always
  • Never10%20%30%40%50%60%70%80%90%Always
  • DOUBLING

  • Never10%20%30%40%50%60%70%80%90%Always
  • Never10%20%30%40%50%60%70%80%90%Always
  • Never10%20%30%40%50%60%70%80%90%Always
  • Never10%20%30%40%50%60%70%80%90%Always
  • LIGHT SENSITIVITY

  • Never10%20%30%40%50%60%70%80%90%Always
  • Never10%20%30%40%50%60%70%80%90%Always
  • Never10%20%30%40%50%60%70%80%90%Always
  • DRY EYES

  • Never10%20%30%40%50%60%70%80%90%Always
  • Never10%20%30%40%50%60%70%80%90%Always
  • Never10%20%30%40%50%60%70%80%90%Always
  • DEPTH PERCEPTION / MOVEMENT IN SPACE

  • Never10%20%30%40%50%60%70%80%90%Always
  • Never10%20%30%40%50%60%70%80%90%Always
  • Never10%20%30%40%50%60%70%80%90%Always
  • Never10%20%30%40%50%60%70%80%90%Always
  • Never10%20%30%40%50%60%70%80%90%Always
  • Never10%20%30%40%50%60%70%80%90%Always
  • Never10%20%30%40%50%60%70%80%90%Always
  • Never10%20%30%40%50%60%70%80%90%Always
  • Never10%20%30%40%50%60%70%80%90%Always
  • Never10%20%30%40%50%60%70%80%90%Always
  • PERIPHERAL VISION

  • Never10%20%30%40%50%60%70%80%90%Always
  • Never10%20%30%40%50%60%70%80%90%Always
  • Never10%20%30%40%50%60%70%80%90%Always
  • Never10%20%30%40%50%60%70%80%90%Always
  • Never10%20%30%40%50%60%70%80%90%Always
  • Never10%20%30%40%50%60%70%80%90%Always
  • Never10%20%30%40%50%60%70%80%90%Always
  • READING

  • Never10%20%30%40%50%60%70%80%90%Always
  • Never10%20%30%40%50%60%70%80%90%Always
  • Never10%20%30%40%50%60%70%80%90%Always
  • Never10%20%30%40%50%60%70%80%90%Always
  • Never10%20%30%40%50%60%70%80%90%Always
  • Never10%20%30%40%50%60%70%80%90%Always
  • Never10%20%30%40%50%60%70%80%90%Always
  • AUDITORY / SPEECH

  • Never10%20%30%40%50%60%70%80%90%Always
  • Never10%20%30%40%50%60%70%80%90%Always
  • Never10%20%30%40%50%60%70%80%90%Always
  • EMOTIONAL STATUS

  • Never10%20%30%40%50%60%70%80%90%Always
  • Never10%20%30%40%50%60%70%80%90%Always
  • Never10%20%30%40%50%60%70%80%90%Always

Please print, fill out the Post Trauma Vision Syndrome and bring it with you for your appointment.