TBI/Post Concussion Questionnaire

Name: Browz Eyeware
Address: 4307 130 Ave SE, Ste 76, Calgary, AB, T2Z 3V8, CA
Telephone: (403) 726-2388
Price range: $000 - $300

Please fill out this questionnaire carefully. Thank you.
Patient’s Name*
First Last
Age
Date of Birth*
MM slash DD slash YYYY
Parent/Guardian's Name (if applicable)
First Last
Whom may we thank for referring you to our office?
Primary Phone Number*
Secondary Phone Number
Email*
Main Visual Concerns
Occupation
Cause of brain injury*
Date of accident(s)*
MEDICAL HISTORY
Date of most recent medical exam
Doctor’s name
Reason/results
List any medications*
List any bad falls, head injuries, car accidents and/or stroke, and year of occurrence*
List any chronic problems*
Any current or past Vestibular Therapy?*
with Whom and when?
Any current or past Occupational Therapy?*
Are you receiving any other therapies? Physical, Chiropractic, massage, and/or Psychological Therapy, etc?
with Whom and when?
Is there any history of the following?
Self Family
Eye Turn/Strabismus
Macula degeneration
Reading disabilities
Lazy Eye/Amblyopia
Dry/Red Eyes
Glaucoma
Diabetes
Other visual conditions
VISUAL HISTORY
When and who performed your the last eye exam:
If you wear glasses, please answer the questions below.
Age of glasses #1
Are they:
- Progressive
- Distance
- Computer
- Reading
- Prescription Sunglasses
Any concerns with them?
Age of glasses #2
Are they:
- Progressive
- Distance
- Computer
- Reading
- Prescription Sunglasses
Any concerns with them?
Age of glasses #3
Are they:
- Progressive
- Distance
- Computer
- Reading
- Prescription Sunglasses
Any concerns with them?
If you wear contact lenses, please write the brand and power of the lenses.
Have you worn “binasal occlusion” where tape is applied to inner part of your glasses?
- Yes
- No
Past eye surgeries?
Date
MM slash DD slash YYYY
Type
Which Eye
Surgeon
Date
MM slash DD slash YYYY
Type
Which Eye
Surgeon
If you have double vision, please answer the questions below.
When did it start?
Is the double image(please circle): side by side, diagonal, up and down or it varies in direction?
Is the double vision occurring when looking at near or far distance?
When does it occur? morning, night, driving, reading, computer, all day
Does the double image disappear if you close one eye?
- Yes
- No
Does your glasses help eliminate your double vision?
Brain Injury Vision Symptom Survey
Symptom Survey
*
- I have a medical diagnosis of brain injury
- I sustained a brain injury without medical diagnosis
- I have not ever sustained a brain injury
Blurry Vision in the distance*
- 0
- 1
- 2
- 3
- 4
Blurry Vision when reading*
- 0
- 1
- 2
- 3
- 4
Fluctuating/inconsistant vision*
- 0
- 1
- 2
- 3
- 4
Headaches*
- 0
- 1
- 2
- 3
- 4
Photophobia (light sensitivity)*
- 0
- 1
- 2
- 3
- 4
Phonophobia (hearing sensitivity)*
- 0
- 1
- 2
- 3
- 4
Double vision*
- 0
- 1
- 2
- 3
- 4
Loses place while reading*
- 0
- 1
- 2
- 3
- 4
Words appear to run together when reading*
- 0
- 1
- 2
- 3
- 4
Poor Memory, forgetful*
- 0
- 1
- 2
- 3
- 4
Attention/Concentration difficulties*
- 0
- 1
- 2
- 3
- 4
Visual memory difficulty*
- 0
- 1
- 2
- 3
- 4
Vision is worse at the end of the day*
- 0
- 1
- 2
- 3
- 4
Rereads reading material in order to comprehend*
- 0
- 1
- 2
- 3
- 4
Difficulty with eye tracking*
- 0
- 1
- 2
- 3
- 4
Eye fatigue*
- 0
- 1
- 2
- 3
- 4
Mental fatigue*
- 0
- 1
- 2
- 3
- 4
Physical fatigue*
- 0
- 1
- 2
- 3
- 4
Spatial disorientation*
- 0
- 1
- 2
- 3
- 4
Night vision worse than day vision*
- 0
- 1
- 2
- 3
- 4
Dizziness*
- 0
- 1
- 2
- 3
- 4
Flashes of light*
- 0
- 1
- 2
- 3
- 4
Irritability*
- 0
- 1
- 2
- 3
- 4
Emotional distress/anxiety*
- 0
- 1
- 2
- 3
- 4
Balance issues*
- 0
- 1
- 2
- 3
- 4
Vertigo/Nausea*
- 0
- 1
- 2
- 3
- 4
Car/motion sickness*
- 0
- 1
- 2
- 3
- 4
Sleep disturbances*
- 0
- 1
- 2
- 3
- 4
Disorganized*
- 0
- 1
- 2
- 3
- 4
Walking difficulties*
- 0
- 1
- 2
- 3
- 4
Poor depth perception*
- 0
- 1
- 2
- 3
- 4
score
Additional comments you would like us to know

	Self	Family
Eye Turn/Strabismus
Macula degeneration
Reading disabilities
Lazy Eye/Amblyopia
Dry/Red Eyes
Glaucoma
Diabetes

TBI/Post Concussion Questionnaire

MEDICAL HISTORY

VISUAL HISTORY

Brain Injury Vision Symptom Survey

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