Persistent Post-Trauma Vision Syndrome Form Patient Name First Last Age Date of Injury MM slash DD slash YYYY Symptoms - Initial/Post Subjective ScoreHeadaches - InitialSelect Number>>012345678910Headaches - PostSelect Number>>012345678910Photophobia - InitialSelect Number>>012345678910Photophobia - PostSelect Number>>012345678910Phonophobia - InitialSelect Number>>012345678910Phonophobia - PostSelect Number>>012345678910Tactile Defensiveness - InitialSelect Number>>012345678910Tactile Defensiveness - PostSelect Number>>012345678910Mental/Physical Fatigue - InitialSelect Number>>012345678910Mental/Physical Fatigue - PostSelect Number>>012345678910Decreased Attention - InitialSelect Number>>012345678910Decreased Attention - PostSelect Number>>012345678910Irritability - InitialSelect Number>>012345678910Irritability - PostSelect Number>>012345678910Distress/Anxiety - InitialSelect Number>>012345678910Distress/Anxiety - PostSelect Number>>012345678910Balance Issues - InitialSelect Number>>012345678910Balance Issues - PostSelect Number>>012345678910Vertigo/Nausea - InitialSelect Number>>012345678910Vertigo/Nausea - PostSelect Number>>012345678910Sleep Disturbances - InitialSelect Number>>012345678910Sleep Disturbances - PostSelect Number>>012345678910Disordered Thinking - InitialSelect Number>>012345678910Disordered Thinking - PostSelect Number>>012345678910Emotionally Sensitive - InitialSelect Number>>012345678910Emotionally Sensitive - PostSelect Number>>012345678910Blurred Vision - InitialSelect Number>>012345678910Blurred Vision - PostSelect Number>>012345678910Motion Smearing or Color Sliding - InitialSelect Number>>012345678910Motion Smearing or Color Sliding - PostSelect Number>>012345678910Tinnitus - InitialSelect Number>>012345678910Tinnitus - PostSelect Number>>012345678910Word Difficulties - InitialSelect Number>>012345678910Word Difficulties - PostSelect Number>>012345678910Avoids/Intolerant of work - InitialSelect Number>>012345678910Avoids/Intolerant of work - PostSelect Number>>012345678910Overwhelmed in busy sound or visual environments - InitialSelect Number>>012345678910Overwhelmed in busy sound or visual environments - PostSelect Number>>012345678910Pulls away from looming objects - InitialSelect Number>>012345678910Pulls away from looming objects - PostSelect Number>>012345678910Upset by objects moving nearby - InitialSelect Number>>012345678910Upset by objects moving nearby - PostSelect Number>>012345678910Staring behavior (low blink rate) - zoning out - InitialSelect Number>>012345678910Staring behavior (low blink rate) - zoning out - PostSelect Number>>012345678910Loses track of place - InitialSelect Number>>012345678910Loses track of place - PostSelect Number>>012345678910Loses place when reading - InitialSelect Number>>012345678910Loses place when reading - PostSelect Number>>012345678910Movement of Text (textual visual aliasing) - InitialSelect Number>>012345678910Movement of Text (textual visual aliasing) - PostSelect Number>>012345678910Comprehension problems reading - InitialSelect Number>>012345678910Comprehension problems reading - PostSelect Number>>012345678910Memory Problems - InitialSelect Number>>012345678910Memory Problems - PostSelect Number>>012345678910Double Vision - InitialSelect Number>>012345678910Double Vision - PostSelect Number>>012345678910