Head Trauma Pre-Screening Questionnaire Date Date Format: MM slash DD slash YYYY Patient's NameProfessional's NamePlease 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 Legend: N= Never , I= Infrequently , S= Sometimes , FO= Fairly Often , A= AlwaysEyes feel tired while reading or doing close work*NISFOAEyes feel uncomfortable while reading or doing close work*NISFOAHeadaches when reading or doing close work*NISFOAFeels sleepy when reading or doing close work*NISFOALoss of concentration when reading or doing close work*NISFOATrouble remembering what he/she has read*NISFOADouble vision*NISFOAWords move, jump, swim, or appear to float on the page*NISFOASlow reader*NISFOAEyes hurt when reading or doing close work*NISFOAEyes feel sore when reading or doing close work*NISFOA"Pulling feeling" around eyes when reading or doing close work*NISFOAWords blur or go in and out of focus when reading or doing close work*NISFOALoss of place while reading or doing close work*NISFOARe-reads the same line of words or omits words when reading*NISFOAOverwhelmed by crowded places (i.e. mall, super-market, etc.)*NISFOALoss of peripheral vision (side vision)*NISFOALoss of balance*NISFOAIllusion of false motion (i.e. room spinning, swaying, etc)*NISFOADifficulty with peripherial vision (side vision)*NISFOADifficulties using both sides of body together*NISFOABothered by repeated patterns*NISFOAPoor sense of direction*NISFOAOverlooks small details (read beak for break) or misreads math symbols (- for +)*NISFOAShort attention span/easily distracted*NISFOASub TotalsTotal Score**Total scores greater than or equal to 16 warrant a consultation with a Developmental Optometrist specializing in Neuro-optometric Rehabilitation.NameThis field is for validation purposes and should be left unchanged.