TBI/Post Concussion Questionnaire

Name: Vision Therapy Institute of Calgary
Address: 8720 MacLeod Trail SE, Ste 3, Calgary, AB, T2H 0M4, CA
Telephone: +1 (403) 258-4482
Price range: $000 - $300

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	Self	Family
Eye Turn/Strabismus
Macula degeneration
Reading disabilities
Lazy Eye/Amblyopia
Dry/Red Eyes
Glaucoma
Diabetes

	0	1	2	3	4	5
Blurry Vision in the distance
Blurry Vision when reading
Fluctuating/inconsistant vision
Headaches
Photophobia (light sensitivity)
Phonophobia (hearing sensitivity)
Double vision
Loses place while reading
Words appear to run together when reading
Poor Memory, forgetful
Attention/Concentration difficulties
Visual memory difficulty
Vision is worse at the end of the day
Rereads reading material in order to comprehend
Difficulty with eye tracking
Eye fatigue
Mental fatigue
Physical fatigue
Spatial disorientation
Night vision worse than day vision
Dizziness
Flashes of light
Irritability
Emotional distress/anxiety
Balance issues
Vertigo/Nausea
Car/motion sickness
Sleep disturbances
Disorganized
Walking difficulties
Poor depth perception

TBI/Post Concussion Questionnaire

MEDICAL HISTORY

VISUAL HISTORY

Traumatic Brain Injury & Post Concussion Syndrome

Panorama Hills (Progressive Optometry)

Bridgeland (Browz Eyeware)

Macleod Trail

Douglasdale – South Trail Crossing