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Persistent Post-Trauma Vision Syndrome Form

Patient Name(Required)
MM slash DD slash YYYY
MM slash DD slash YYYY
Please checkmark symptoms currently experiencing and rate the severity (0=none to 10=worst)
Headaches
Photophobia
Phonophobia
Tactile Defensiveness
Mental/Physical Fatigue
Decreased Attention
Irritability
Distress/Anxiety
Balance Issues
Vertigo/Nausea
Sleep Disturbance
Disordered Thinking
Emotionally Sensitive
Blurred Vision
Traffic Motion/Color sliding
Tinnitus
Speech Difficulties
Activity Intolerance
Confusion in busy sound or visual environments
Pulls away from looming objects
Upset by objects moving nearby
Staring behavior (low blink rate)
Spatial disorientation
Losing place when reading
Movement of Text (Textual Visual Aliasing)
Comprehension problems reading
Visual memory problems
Double Vision