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Home » Patient Forms » Head Trauma Pre-Screening Questionnaire

Head Trauma Pre-Screening Questionnaire

MM slash DD slash YYYY
Please rate the following signs and symptoms according to your current observations and/or your patient's current reports about how his/her eyes feel. Indicate the frequency of these signs and symptoms using the following number scale:
Score 0 for Never, 1 for Infrequently, 2 for Sometimes, 3 for Fairly Often, 4 for Always
Eyes feel tired while reading or doing close work(Required)
Eyes feel uncomfortable while reading or doing close work(Required)
Headaches when reading or doing close work(Required)
Feels sleepy when reading or doing close work(Required)
Loss of concentration when reading or doing close work(Required)
Trouble remembering what he/she has read(Required)
Double vision(Required)
Words move, jump, swim, or appear to float on the page(Required)
Slow reader(Required)
Eyes hurt when reading or doing close work(Required)
Eyes feel sore when reading or doing close work(Required)
"Pulling feeling" around eyes when reading or doing close work(Required)
Words blur or go in and out of focus when reading or doing close work(Required)
Loss of place while reading or doing close work(Required)
Re-reads the same line of words or omits words when reading(Required)
Overwhelmed by crowded places (i.e. mall, super-market, etc.)(Required)
Loss of peripheral vision (side vision)(Required)
Loss of balance(Required)
Illusion of false motion (i.e. room spinning, swaying, etc)(Required)
Difficulty with peripherial vision (side vision)(Required)
Difficulties using both sides of body together(Required)
Bothered by repeated patterns(Required)
Poor sense of direction(Required)
Overlooks small details (read beak for break) or misreads math symbols (- for +)(Required)
Short attention span/easily distracted(Required)
**Total scores greater than or equal to 16 warrant a consultation with a Developmental Optometrist specializing in Neuro-optometric Rehabilitation.