Signs & Symptoms Checklist

Please answer the following questions about how your eyes feel when reading or doing close work. This survey is not a substitute for consulting a physician, and does not provide diagnoses.

Use the following scale to choose the most appropriate number for each situation:

0 - Never
1 - Infrequently
2 - Sometimes
3 - Fairly Often
4 - Always

***It is important that you answer each question as best as you can.***

Score Interpretation:
A score of 16 or higher indicates that you or your child may have a symptomatic eye teamwork problem that can negatively impact school performance, reading, learning, and sports. Please note that while a score less than 16 means that the individual is not considered symptomatic, it does not mean a vision problem does not exist. Please give our office a call to schedule an evaluation to diagnose and treat the vision problems causing these symptoms. If you are curious about some symptoms you or your child are experiencing, please give us a call and someone from our team will help you determine if an initial evaluation is indicated. If you have any additional questions, please give us a call at 239-682-0945. You can also request an appointment now.

This symptom survey is derived from the National Institute of Health’s Convergence Insufficiency Treatment Trial. For full text of the study visit http://archopht.ama-assn.org/cgi/reprint/126/10/1336.