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Home » Brain Injury Vision Symptom Survey (BIVSS) Questionnaire

Brain Injury Vision Symptom Survey (BIVSS) Questionnaire

Brain Injury Vision Symptom Survey (BIVSS) Questionnaire

INSTRUCTIONS: Please check the most appropriate box that best matches your symptoms today.
Please rate each symptom.
How often does each occur? (Check a box)
EYESIGHT CLARITY
Distance vision blurred and not clear—even with lenses
- Never
- Seldom
- Occasionally
- Frequently
- Always
Near vision blurred and not clear—even with lenses
- Never
- Seldom
- Occasionally
- Frequently
- Always
Poor night vision/ can’t see well to drive at night
- Never
- Seldom
- Occasionally
- Frequently
- Always
Clarity of vision changes or fluctuates during the day
- Never
- Seldom
- Occasionally
- Frequently
- Always
VISUAL COMFORT
Eye discomfort/ sore eyes/ eyestrain
- Never
- Seldom
- Occasionally
- Frequently
- Always
Headaches or dizziness after using eyes
- Never
- Seldom
- Occasionally
- Frequently
- Always
Eye fatigue/ very tired after using eyes all day
- Never
- Seldom
- Occasionally
- Frequently
- Always
Feel “pulling” around the eyes
- Never
- Seldom
- Occasionally
- Frequently
- Always
DOUBLING
Double vision—especially when tired
- Never
- Seldom
- Occasionally
- Frequently
- Always
Have to close or cover one eye to see clearly
- Never
- Seldom
- Occasionally
- Frequently
- Always
Print moves in and out of focus when reading
- Never
- Seldom
- Occasionally
- Frequently
- Always
LIGHT SENSITIVITY
Normal indoor lighting is uncomfortable- too much glare
- Never
- Seldom
- Occasionally
- Frequently
- Always
Outdoor light is too bright- have to use sunglasses
- Never
- Seldom
- Occasionally
- Frequently
- Always
Poor handwriting (spacing, sizing, legibility)
- Never
- Seldom
- Occasionally
- Frequently
- Always
DRY EYES
Eyes feel “dry” and sting
- Never
- Seldom
- Occasionally
- Frequently
- Always
“Stare” into space without blinking
- Never
- Seldom
- Occasionally
- Frequently
- Always
Have to rub the eyes a lot
- Never
- Seldom
- Occasionally
- Frequently
- Always
DEPTH PERCEPTION
Clumsiness/ misjudge where objects really are
- Never
- Seldom
- Occasionally
- Frequently
- Always
Lack of confidence- walking/ missing steps/ stumbling
- Never
- Seldom
- Occasionally
- Frequently
- Always
Poor handwriting (spacing, sizing, legibility)
- Never
- Seldom
- Occasionally
- Frequently
- Always
PERIPHERAL VISION
Side vision distorted/ objects move or change position
- Never
- Seldom
- Occasionally
- Frequently
- Always
What looks straight ahead—isn’t always straight ahead
- Never
- Seldom
- Occasionally
- Frequently
- Always
Avoid crowds/ can’t tolerate “visually-busy” places
- Never
- Seldom
- Occasionally
- Frequently
- Always
READING
Short attention span/ easily distracted when reading
- Never
- Seldom
- Occasionally
- Frequently
- Always
Difficulty/ slowness with reading and writing
- Never
- Seldom
- Occasionally
- Frequently
- Always
Poor reading comprehension/ can’t remember what was read
- Never
- Seldom
- Occasionally
- Frequently
- Always
Confusion of words/ skip words during reading
- Never
- Seldom
- Occasionally
- Frequently
- Always
Lose place/ have to use finger to not lose place when reading
- Never
- Seldom
- Occasionally
- Frequently
- Always
Name
First Last
Phone
Email

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Find all of our online forms here.

Brain Injury Vision Symptom Survey Submittable Form

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Family Eye Care & Vision Therapy

694 S Tamiami Trail
Osprey, FL 34229

Phone: 941-966-6700
Email: contact@familyeyecarevt.com
(Do not send personal health information by email.)

Monday: 8:30 AM - 5:00 PM
Tuesday: 8:30 AM - 6:00 PM
Wednesday: 8:30 AM - 5:00 PM
Thursday: 8:30 AM - 5:00 PM
Friday: 8:30 AM - 12:30 PM
Saturday: Closed
Sunday: Closed

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Family Eye Care & Vision Therapy - Located at 694 S. Tamiami Trail, Osprey, Florida 34229 Phone: 941-966-6700 https://www.familyeyecarevt.com/

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