Brain Injury Vision Symptom Survey (BIVSS) Questionnaire

Test

Brain Injury Vision Symptom Survey (BIVSS) Questionnaire

INSTRUCTIONS: Please click the appropriate response from the dropdown menu under each question

Please rate each symptom

Distance vision blurred (Not clear with or without lenses)

Near vision blurred (Not clear with or without lenses)

Clarity of vision changes or fluctuates during the day

Poor night vision / can’t see well to drive at night

Eye Discomfort / Sore eyes / Eyestrain

Headaches or dizziness after using eyes

Eye fatigue (Very tired after using eyes all day)

Feel “pulling” around the eyes

Double vision (Especially when tired)

Have to close or cover one eye to see clearly

Print moves in and out of focus when reading

Normal indoor lighting is uncomfortable (Too much glare)

Outdoor light too bright (Have to use sunglasses)

Indoors fluorescent lighting is bothersome or annoying

Eyes feel “dry” and sting

“Stare” into space without blinking

Have to rub the eyes a lot

Clumsiness / misjudge where objects really are

Lack of confidence walking / missing steps / stumbling

Poor handwriting (spacing, size, legibility)

Side vision distorted / objects move or change position

What looks straight ahead isn’t always straight ahead

Avoid crowds / can’t tolerate “visually-busy” places

Short attention span/easily distracted when reading

Difficulty / slowness with reading and writing

Poor reading comprehension/can’t remember what was read

Confusion of words / skip words during reading

Lose place/use finger not to lose place when reading

Test

Brain Injury Vision Symptom Survey (BIVSS) Questionnaire

Please rate each symptom

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