Neuro-Optometric Rehabilitation Questionnaire Patient Name(Required) First Last Date of Birth(Required) MM slash DD slash YYYY Brain Injury Date(Required) MM slash DD slash YYYY Please check the signs and symptoms that best describe how you feel or are performing.Focusing Deficiencies Blurry or fluctuating near vision Blurry distance vision Blurry distance vision AFTER near work Eye fatigue after short period of reading or near work Holds book too closely Has difficulty sustaining near tasks Has red eyes Avoids near visual tasks Eyes hurt, burn, or tire while reading or doing near work Headaches with near work Excessive rubbing, blinking, or tearing of eyes Eye Pointment Deficiencies Reports eye strain with reading, writing, or near work Reports frontal headaches associated with visual tasks Squints, closes, or covers one eye during visual tasks Reports that letters, words, or both appear to float, jump, or move around on the page Has abnormal posture when doing near visual tasks (tilting head or body) Intermittent double vision Can’t figure out where to look through spectacle bifocals Eye Movement Deficiencies Excessive head movement when reading Frequent loss of place when reading Omission of small words or skipping of lines when reading Use of a finger or marker when reading Lack of comprehension when reading Re-reads lines unknowingly Visual - Spatial Deficiencies The world seems to be unstable The floor or walls appear to be tilted Lack of coordination and balance Clumsy; falls and bumps into things often Tendency to work with one side of the body while the other side doesn’t participate Tendency to drift to one side while walking or while steering Knocks over objects or misses objects while reaching for them Inaccuracy with keys in locks or touching buttons Dizziness Motion Sickness Consistently leans or turns to one side Visual Analysis Deficiencies Has trouble telling time on a clock with minute and hour hands Confuses likenesses and minor differences No longer recognizes familiar written words Mistakes words with similar beginnings Difficulty recognizing the same word repeated on a page Difficulty recognizing letters or simple forms Difficulty distinguishing the main idea from insignificant details Has trouble writing and remembering letters and numbers Visual Field Deficiencies Can’t find objects to one side Bumps into objects on one side Is surprised by objects or people that seem to pop into view Only eats food on one side of plate Ignores space on one side of the room Says they can’t see out of one eye Sensory Integration Deficiencies Can only do one thing at a time Doesn’t notice peripheral objects while concentrating visually on something Can’t carry on an intelligent conversation while doing some motor task Has trouble multi-tasking Thinking speed is slower PhoneThis field is for validation purposes and should be left unchanged.