Convergence Insufficiency Symptom Survery Please answer the questions about how your eyes feel when reading or doing close work.1. Do your eyes feel tired when reading or doing close work?* Never Rarely Sometimes Frequently Constantly 2. Do your eyes feel uncomfortable when reading or doing close work?* Never Rarely Sometimes Frequently Constantly 3. Do you have headaches when reading or doing close work?* Never Rarely Sometimes Frequently Constantly 4. Do you feel sleepy when reading or doing close work?* Never Rarely Sometimes Frequently Constantly 5. Do you lose concentration when reading or doing close work?* Never Rarely Sometimes Frequently Constantly 6. Do you have trouble remembering what you have read?* Never Rarely Sometimes Frequently Constantly 7. Do you have double vision when reading or doing close work?* Never Rarely Sometimes Frequently Constantly 8. Do you see the words move, jump, swim or appear to float on the page when reading or doing close work?* Never Rarely Sometimes Frequently Constantly 9. Do you feel like you read slowly?* Never Rarely Sometimes Frequently Constantly 10. Do your eyes hurt when reading or doing close work?* Never Rarely Sometimes Frequently Constantly 11. Do your eyes ever feel sore when reading or doing close work?* Never Rarely Sometimes Frequently Constantly 12. Do you feel a "pulling" feeling around your eyes when reading or doing close work?* Never Rarely Sometimes Frequently Constantly 13. Do you notice the words blurring or coming in and out of focus when reading or doing close work?* Never Rarely Sometimes Frequently Constantly 14. Do you lose your place while reading or doing close work?* Never Rarely Sometimes Frequently Constantly This field is hidden when viewing the formScore Name* First Last Would you prefer to be contacted by email or phone?* Email Phone Email* Phone* Δ
