Clinical Surveys Convergence Insufficiency Symptom SurveyClinician instructions:Please answer the following questions about how your eyes feel when reading or doing close work. Name * First Name Last Name Email * Do your eyes feel tired when reading or doing close work? * Please Select Never Infrequently Sometimes Fairly Often Always Do your eyes feel uncomfortable when reading or doing close work? * Please Select Never Infrequently Sometimes Fairly Often Always Do you have headaches when reading or doing close work? * Please Select Never Infrequently Sometimes Fairly Often Always Do you feel sleepy when reading or doing close work? * Please Select Never Infrequently Sometimes Fairly Often Always Do you lose concentration when reading or doing close work? * Please Select Never Infrequently Sometimes Fairly Often Always Do you have trouble remembering what you have read? * Please Select Never Infrequently Sometimes Fairly Often Always Do you have double vision when reading or doing close work? * Please Select Never Infrequently Sometimes Fairly Often Always Do you see the words move, jump, swim or appear to float on the page when reading or doing close work? * Please Select Never Infrequently Sometimes Fairly Often Always Do you feel like you read slowly? * Please Select Never Infrequently Sometimes Fairly Often Always Do your eyes ever hurt when reading or doing close work? * Please Select Never Infrequently Sometimes Fairly Often Always Do your eyes ever feel sore when reading or doing close work? * Please Select Never Infrequently Sometimes Fairly Often Always Do you feel a "pulling" feeling around your eyes when reading or doing close work? * Please Select Never Infrequently Sometimes Fairly Often Always Do you notice the words blurring or coming in and out of focus when reading or doing close work? * Please Select Never Infrequently Sometimes Fairly Often Always Do you lose your place while reading or doing close work? * Please Select Never Infrequently Sometimes Fairly Often Always Do you have to re-read the same line of words when reading? * Please Select Never Infrequently Sometimes Fairly Often Always Thank you!
