Post-Head Injury/Stroke Questionnaire
Patient Name *
Your answer
Patient's Age *
Your answer
Date of Injury/Stroke *
MM
/
DD
/
YYYY
Today's Date *
MM
/
DD
/
YYYY
Please review the following statements and check the box if true.
I have had a medical diagnosis of brain injury or stroke. *
Required
I suffered a brain injury without medical diagnosis. *
Required
Eyesight Clarity
Distance vision blurred and not clear (even with lenses)
Never
Always
Near vision blurred and not clear (even with lenses)
Never
Always
Clarity of vision changes or fluctuates during the day
Never
Always
Poor night vision/can't see well enough to drive at night
Never
Always
Visual Comfort
Eye discomfort/sore eyes/eye strain
Never
Always
Headaches or dizziness after using eyes
Never
Always
Eye fatigue/very tired after using eyes all day
Never
Always
Feel "pulling" around the eyes
Never
Always
Doubling
Double-vision - especially when tired
Never
Always
Have to close or cover one eye to see clearly
Never
Always
Text on page moves in and out of focus when reading
Never
Always
Light Sensitivity
Normal indoor lighting is uncomfortable - too much glare
Never
Always
Outdoor light too bright - have to use sunglasses
Never
Always
Indoor fluorescent lighting is bothersome or annoying
Never
Always
Dry Eyes
Eyes feel "dry" and sting
Never
Always
"Stare" into space with blinking
Never
Always
Have to rub your eyes often
Never
Always
Depth Perception
Clumsiness/misjudge where objects really are
Never
Always
Lack of confidence walking, often missing steps/stumbling
Never
Always
Poor handwriting (spacing, size, legibility)
Never
Always
Peripheral Vision
Side vision distorted/objects move or change position
Never
Always
What looks straight ahead isn't always straight ahead
Never
Always
Avoid crowds/can't tolerate "visually busy" places
Never
Always
Reading
Short attention span/easily distracted when reading
Never
Always
Difficulty/slowness with reading and writing
Never
Always
Poor reading comprehension/can't remember what was read
Never
Always
Confusion of words/skip words during reading
Never
Always
Lose place/have to use finger in order to keep place when reading
Never
Always
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