Name: InVision
Address: 2715 Broadbent Parkway NE, Suite D, Albuquerque, NM, 87107
Telephone: +1-(505) 341-2020
Price range: $$

Please read each question carefully. Rate each question with the following scale

0 – Never 1 – Not very often 2 – Sometimes 3 – Fairly Often 4 – Always

Name of Patient*
Today's Date
MM slash DD slash YYYY
Phone*
Do your eyes feel tired when reading or doing close work?*
Do your eyes feel uncomfortable when reading or doing close work?*
Do you have headaches when reading or doing close work?*
Do you feel sleepy when reading or doing close work?*
Do you lose concentration when reading or doing close work?*
Do you have trouble remembering what you have read?*
Do you have double vision when reading or doing close work?*
Do you see the words move, jump, swim or appear to float on the page when reading or doing close work?*
Do you feel like you read slowly?*
Do your eyes ever hurt when reading or doing close work?*
Do your eyes ever feel sore when reading or doing close work?*
Do you feel a “pulling” feeling around your eyes when reading or doing close work?*
Do you notice the words blurring or coming in and out of focus when reading or doing close work?*
Do you lose your place while reading or doing close work?*
Do you have to re-read the same line of words when reading?*
Phone
This field is for validation purposes and should be left unchanged.

Please do not submit any Protected Health Information (PHI)

Convergence Insufficiency Symptom Survey