Visual-Vestibular Symptom Survey

Instructions: Please rate the severity of each symptom on a scale of 1-10 (1 = very mild, 10 = very severe). Write your rating in the space provided next to each item.

Visual Motion Sensitivity

1. Dizzy/unsteady in busy visual environments (e.g., grocery store aisles)?

2. Disoriented when watching fast-moving objects (e.g., sports games)?

3. Dizziness or nausea when scrolling on a screen?

4. Dizziness when viewing patterned floors or walls?

5. Unsteadiness on escalators, elevators, or moving sidewalks?

6. Worsening dizziness under fluorescent or flickering lights?

7. Motion sickness or dizziness when riding in a car?

Eye Movement and Tracking Difficulites​​​​​​​

8. Eyes feel jumpy or unstable when trying to focus?

9. Dizziness or nausea while reading?

10. Difficulty following a moving target without dizziness

11. Double or blurred vision when fatigued?

12. Losing place or skipping lines while reading?

Binocular Vision and Depth Perception

13. Off-balance when switching focus between near and far objects?

14. Unsteadiness when walking down stairs?

15. Difficulty judging distances (e.g., parking, reaching)?

16. Relief of dizziness when closing one eye?

17. Headaches, eye strain, or dizziness after visual tasks?

Vestibular-Visual Integration

18. Quick head movements causing dizziness?

19. Disorientation when transitioning from sitting to standing?

20. Need to steady yourself after bending over?

21. Dizziness when bending to tie shoes?

22. Instability when walking in wide open spaces

Balance, Orientation and Spatial Awareness

23. Bumping into objects or walls?

24. Sensation that the ground is moving or tilting?

25. Difficulty walking in a straight line?

26. Feeling pulled to one side while walking?

27. Better balance with dim lighting or eyes closed?

Visual Overload and Fatigue​​​​​​​

28. Visual clutter overwhelming or worsening symptoms?

29. Feeling exhausted after heavy visual tasks?

30. Symptom relief with eye rest or visual breaks?

Additional Information

Other symptoms you'd like to share:

Are symptoms worse at certain times of the day?

History of concussion, whiplash, or head injury?

Currently receiving vestibular therapy? Yes / No

Thank you for completing this survey. This information helps us better understand your visual and vestibular needs.

Patient Name:

Signature:(initial)

Date: