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

"*" indicates required fields

Name

This field is for validation purposes and should be left unchanged.

Name of Patient*

Today's Date

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?*

Please do not submit any Protected Health Information (PHI)

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InVision Optometry - Neuro-optometrist in NM

Convergence Insufficiency Symptom Survey

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