POST-TRAUMA VISION SYNDROME – Symptom Checklist Date of Brain Injury MM slash DD slash YYYY Name* First Last HiddenDate MM slash DD slash YYYY DOB MM slash DD slash YYYY Please check frequency of each symptom: EYESIGHT CLARITYPlease check frequency of each symptom, and if applicable, use the last column to indicate if the symptom existed before your injuryBlurred distance vision - even with lensesNever10%20%30%40%50%60%70%80%90%Always Please check if you had this symptom before injuryBlurred near vision - even with lensesNever10%20%30%40%50%60%70%80%90%Always Please check if you had this symptom before injuryClarity of vision fluctuates throughout dayNever10%20%30%40%50%60%70%80%90%Always Please check if you had this symptom before injuryPoor night visionNever10%20%30%40%50%60%70%80%90%Always Please check if you had this symptom before injuryVISUAL COMFORTEye discomfort / sore eyes / eyestrainNever10%20%30%40%50%60%70%80%90%Always Please check if you had this symptom before injuryHeadaches or dizziness with visual tasksNever10%20%30%40%50%60%70%80%90%Always Please check if you had this symptom before injuryEye fatigue /very tired after using eyes all dayNever10%20%30%40%50%60%70%80%90%Always Please check if you had this symptom before injuryPHYSICAL COMFORT / BEHAVIORSHeadaches, non-visually relatedNever10%20%30%40%50%60%70%80%90%Always Please check if you had this symptom before injuryDizziness or NauseaNever10%20%30%40%50%60%70%80%90%Always Please check if you had this symptom before injuryAttention / Concentration difficultiesNever10%20%30%40%50%60%70%80%90%Always Please check if you had this symptom before injuryConfusion / disordered thinkingNever10%20%30%40%50%60%70%80%90%Always Please check if you had this symptom before injuryTactile defensivenessNever10%20%30%40%50%60%70%80%90%Always Please check if you had this symptom before injuryMental / Physical fatigueNever10%20%30%40%50%60%70%80%90%Always Please check if you had this symptom before injuryAvoids intolerant workNever10%20%30%40%50%60%70%80%90%Always Please check if you had this symptom before injuryDOUBLINGDouble vision - Near (ie reading, computer)Never10%20%30%40%50%60%70%80%90%Always Please check if you had this symptom before injuryDouble vision - Distance (ie TV, driving)Never10%20%30%40%50%60%70%80%90%Always Please check if you had this symptom before injuryCloses / covers one eye to see betterNever10%20%30%40%50%60%70%80%90%Always Please check if you had this symptom before injuryPrint moves in and out of focus when readingNever10%20%30%40%50%60%70%80%90%Always Please check if you had this symptom before injuryLIGHT SENSITIVITYDiscomfort with normal indoor lightingNever10%20%30%40%50%60%70%80%90%Always Please check if you had this symptom before injuryDiscomfort with indoor fluorescent lightingNever10%20%30%40%50%60%70%80%90%Always Please check if you had this symptom before injuryOutdoor light too brightNever10%20%30%40%50%60%70%80%90%Always Please check if you had this symptom before injuryDRY EYESEyes burn / sting / waterNever10%20%30%40%50%60%70%80%90%Always Please check if you had this symptom before injury“Stare” into space without blinkingNever10%20%30%40%50%60%70%80%90%Always Please check if you had this symptom before injuryRub eyes oftenNever10%20%30%40%50%60%70%80%90%Always Please check if you had this symptom before injuryDEPTH PERCEPTION / MOVEMENT IN SPACESpatial disorientation - Misjudge where objects areNever10%20%30%40%50%60%70%80%90%Always Please check if you had this symptom before injuryDifficulties with balance, coordination, postureNever10%20%30%40%50%60%70%80%90%Always Please check if you had this symptom before injuryClumsinessNever10%20%30%40%50%60%70%80%90%Always Please check if you had this symptom before injuryLack of confidence walking / mis-steps / stumblingNever10%20%30%40%50%60%70%80%90%Always Please check if you had this symptom before injuryConsistently stays to one side of hallway or roomNever10%20%30%40%50%60%70%80%90%Always Please check if you had this symptom before injuryBumps into objects when walkingNever10%20%30%40%50%60%70%80%90%Always Please check if you had this symptom before injuryPerception of floor being tiltedNever10%20%30%40%50%60%70%80%90%Always Please check if you had this symptom before injuryPoor walking posture: Leans back on heels, forward, or to one side when walking, standing, or seated in chairNever10%20%30%40%50%60%70%80%90%Always Please check if you had this symptom before injuryLeaves one side plate uneaten / one side body unshavenNever10%20%30%40%50%60%70%80%90%Always Please check if you had this symptom before injuryPoor handwriting (spacing, size, legibility)Never10%20%30%40%50%60%70%80%90%Always Please check if you had this symptom before injuryPERIPHERAL VISIONMissing part(s) of side visionNever10%20%30%40%50%60%70%80%90%Always Please check if you had this symptom before injuryUnstable side visionNever10%20%30%40%50%60%70%80%90%Always Please check if you had this symptom before injuryStationary objects appear to move or changeNever10%20%30%40%50%60%70%80%90%Always Please check if you had this symptom before injuryWhat looks straight ahead, is not straight aheadNever10%20%30%40%50%60%70%80%90%Always Please check if you had this symptom before injuryAvoid crowds / dislikes “visually busy” placesNever10%20%30%40%50%60%70%80%90%Always Please check if you had this symptom before injuryPulls away from looming objectsNever10%20%30%40%50%60%70%80%90%Always Please check if you had this symptom before injuryUpset by objects moving nearbyNever10%20%30%40%50%60%70%80%90%Always Please check if you had this symptom before injuryREADINGShort attention span / easily distractedNever10%20%30%40%50%60%70%80%90%Always Please check if you had this symptom before injurySlowness with readingNever10%20%30%40%50%60%70%80%90%Always Please check if you had this symptom before injuryPoor comprehension / memory of what was readNever10%20%30%40%50%60%70%80%90%Always Please check if you had this symptom before injuryConfusion of wordsNever10%20%30%40%50%60%70%80%90%Always Please check if you had this symptom before injuryLoss of place / Skips wordsNever10%20%30%40%50%60%70%80%90%Always Please check if you had this symptom before injuryMovement of textNever10%20%30%40%50%60%70%80%90%Always Please check if you had this symptom before injuryCannot find beginning of next line readingNever10%20%30%40%50%60%70%80%90%Always Please check if you had this symptom before injuryAUDITORY / SPEECHEasily overwhelmed by soundsNever10%20%30%40%50%60%70%80%90%Always Please check if you had this symptom before injuryTinnitus (ringing in ears)Never10%20%30%40%50%60%70%80%90%Always Please check if you had this symptom before injurySpeaking difficultiesNever10%20%30%40%50%60%70%80%90%Always Please check if you had this symptom before injuryEMOTIONAL STATUSIrritabilityNever10%20%30%40%50%60%70%80%90%Always Please check if you had this symptom before injuryDistress / AnxietyNever10%20%30%40%50%60%70%80%90%Always Please check if you had this symptom before injuryEmotionally SensitiveNever10%20%30%40%50%60%70%80%90%Always Please check if you had this symptom before injury Please print, fill out the Post Trauma Vision Syndrome and bring it with you for your appointment.