Concussion, Brain Injury and Vision Quiz

Total score greater than 20 indicates a higher risk for a vision problem. Further evaluation is recommended.

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1. Do your eyes feel tired when reading or doing close work?

Never

Not too Often

Sometimes

Fairly Often

Always

2. Do your eyes feel uncomfortable when reading or doing close work?

Never

Not too Often

Sometimes

Fairly Often

Always

3. Do you have headaches when reading or doing close work?

Never

Not too Often

Sometimes

Fairly Often

Always

4. Do you feel sleepy when reading or doing close work?

Never

Not too Often

Sometimes

Fairly Often

Always

5. Do you lose concentration when reading or doing close work?

Never

Not too Often

Sometimes

Fairly Often

Always

6. Do you have trouble remembering what you have read?

Never

Not too Often

Sometimes

Fairly Often

Always

7. Do you have double vision when reading or doing close work?

Never

Not too Often

Sometimes

Fairly Often

Always

8. Do you see the words move, jump, swim, or appear to float on the page when reading or doing close work?

Never

Not too Often

Sometimes

Fairly Often

Always

9. Do you feel like you read slowly?

Never

Not too Often

Sometimes

Fairly Often

Always

10. Do your eyes ever hurt when reading or doing close work?

Never

Not too Often

Sometimes

Fairly Often

Always

11. Do your eyes ever feel sore when reading or doing close work?

Never

Not too Often

Sometimes

Fairly Often

Always

12. Do you feel a “pulling” feeling around your eyes when reading or doing close work?

Never

Not too Often

Sometimes

Fairly Often

Always

13. Do you notice the words blurring or coming in and out of focus when reading or doing close work?

Never

Not too Often

Sometimes

Fairly Often

Always

14. Do you lose your place while reading or doing close work?

Never

Not too Often

Sometimes

Fairly Often

Always

15. Do you have to re-read the same line of words when reading?

Never

Not too Often

Sometimes

Fairly Often

Always

16. Do you have blurred vision when looking far away?

Never

Not too Often

Sometimes

Fairly Often

Always

17. Do you have a loss of peripheral (or side) vision?

Never

Not too Often

Sometimes

Fairly Often

Always

18. Do you feel dizzy or foggy?

Never

Not too Often

Sometimes

Fairly Often

Always

19. Do lights bother you?

Never

Not too Often

Sometimes

Fairly Often

Always

20. Do you cover or close one eye to see well?

Never

Not too Often

Sometimes

Fairly Often

Always

21. Do you have to take a lot of breaks during reading and close work?

Never

Not too Often

Sometimes

Fairly Often

Always

22. Are you bothered by riding in a car or walking down the aisle in a store?

Never

Not too Often

Sometimes

Fairly Often

Always

23. Do you have any trouble with balance while walking or standing?

Never

Not too Often

Sometimes

Fairly Often

Always

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