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 CLARITYDistance vision blurred and not clear—even with lensesNeverSeldomOccasionallyFrequentlyAlwaysNear vision blurred and not clear—even with lensesNeverSeldomOccasionallyFrequentlyAlwaysPoor night vision/ can’t see well to drive at nightNeverSeldomOccasionallyFrequentlyAlwaysClarity of vision changes or fluctuates during the dayNeverSeldomOccasionallyFrequentlyAlwaysVISUAL COMFORTEye discomfort/ sore eyes/ eyestrainNeverSeldomOccasionallyFrequentlyAlwaysHeadaches or dizziness after using eyesNeverSeldomOccasionallyFrequentlyAlwaysEye fatigue/ very tired after using eyes all dayNeverSeldomOccasionallyFrequentlyAlwaysFeel “pulling” around the eyesNeverSeldomOccasionallyFrequentlyAlwaysDOUBLINGDouble vision—especially when tiredNeverSeldomOccasionallyFrequentlyAlwaysHave to close or cover one eye to see clearlyNeverSeldomOccasionallyFrequentlyAlwaysPrint moves in and out of focus when readingNeverSeldomOccasionallyFrequentlyAlwaysLIGHT SENSITIVITYNormal indoor lighting is uncomfortable- too much glareNeverSeldomOccasionallyFrequentlyAlwaysOutdoor light is too bright- have to use sunglassesNeverSeldomOccasionallyFrequentlyAlwaysPoor handwriting (spacing, sizing, legibility)NeverSeldomOccasionallyFrequentlyAlwaysDRY EYESEyes feel “dry” and stingNeverSeldomOccasionallyFrequentlyAlways“Stare” into space without blinkingNeverSeldomOccasionallyFrequentlyAlwaysHave to rub the eyes a lotNeverSeldomOccasionallyFrequentlyAlwaysDEPTH PERCEPTIONClumsiness/ misjudge where objects really areNeverSeldomOccasionallyFrequentlyAlwaysLack of confidence- walking/ missing steps/ stumblingNeverSeldomOccasionallyFrequentlyAlwaysPoor handwriting (spacing, sizing, legibility)NeverSeldomOccasionallyFrequentlyAlwaysPERIPHERAL VISIONSide vision distorted/ objects move or change positionNeverSeldomOccasionallyFrequentlyAlwaysWhat looks straight ahead—isn’t always straight aheadNeverSeldomOccasionallyFrequentlyAlwaysAvoid crowds/ can’t tolerate “visually-busy” placesNeverSeldomOccasionallyFrequentlyAlwaysREADINGShort attention span/ easily distracted when readingNeverSeldomOccasionallyFrequentlyAlwaysDifficulty/ slowness with reading and writingNeverSeldomOccasionallyFrequentlyAlwaysPoor reading comprehension/ can’t remember what was readNeverSeldomOccasionallyFrequentlyAlwaysConfusion of words/ skip words during readingNeverSeldomOccasionallyFrequentlyAlwaysLose place/ have to use finger to not lose place when readingNeverSeldomOccasionallyFrequentlyAlwaysName First Last PhoneEmail