Brain Injury Vision Symptom Survey

When was your brain injury? (years/months ago)(Required)

My age is(Required)

Would you like to be contacted by our staff dependent on the results of your quiz?(Required)

What is your email?(Required)

What is your phone number? (optional)

Please select which of the following applies to you(Required)

If you HAVE had a brain injury, please list the cause of injury(Required)

If this question is not applicable to you, answer “N/A”

Clarity of vision changes or fluctuates throughout the day(Required)

Eye discomfort/sore eyes/eyestrain(Required)

Headaches or dizziness after using eyes(Required)

Eye fatigue/very tired after using eyes all day(Required)

Feel "pulling" around the eyes(Required)

Print moves in and out of focus when reading(Required)

Normal indoor lighting is uncomfortable(Required)

Indoor fluorescent lighting is bothersome or annoying(Required)

Clumsiness/misjudging where objects really are(Required)

Lack of confidence walking/missing steps/stumbling(Required)

Side vision distorted/objects move or change position(Required)

What looks straight ahead – isn't always straight ahead(Required)

Avoids crowds/can't tolerate "visually busy" places(Required)

Short attention span/easily distracted when reading(Required)

Difficulty/slowness with reading and writing(Required)

Poor reading comprehension/can't remember what was read(Required)

Confusion of words/skips words during reading(Required)

Lose place/have to use finger to not lose place when reading(Required)

Phone

This field is for validation purposes and should be left unchanged.

brain injury vision symptom survey