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.

Choose as follows: 0 = Never, 1 = Infrequently, 2 = Sometimes, 3 = Fairly Often, 4 = Always

SYMPTOMSCORE
Do your eyes feel tired when reading or doing close work?0 1 2 3 4
Do your eyes feel uncomfortable when reading or doing close work?0 1 2 3 4
Do you have headaches when reading or doing close work?0 1 2 3 4
Do you feel sleepy when reading or doing close work?0 1 2 3 4
Do you lose concentration when reading or doing close work?0 1 2 3 4
Do you have trouble remembering what you have read?

0 1 2 3 4

Do you have double vision when reading or doing close work?0 1 2 3 4
Do you see the words move, jump, swim or appear to float on the page?0 1 2 3 4
Do you feel like you read slowly?0 1 2 3 4
Do your eyes ever hurt when reading or doing close work?0 1 2 3 4
Do your eyes ever feel sore when reading or doing close work?0 1 2 3 4
Do you feel a pulling feeling around your eyes when reading or doing close work?0 1 2 3 4
Do you notice the words blurring or coming in and out of focus when reading or doing close work?0 1 2 3 4
Do you lose your place while reading or doing close work?0 1 2 3 4
Do you have to reread the same line of words when reading?0 1 2 3 4
TOTAL POINTS

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.