Visual Symptoms Survey
Please answer the following 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
Occasionally
Often
Always
2. Do your eyes feel uncomfortable when reading or doing close work?
Never
Rarely
Occasionally
Often
Always
3. Do you have headaches when reading or doing close work?
Never
Rarely
Occasionally
Often
Always
4. Do you feel sleepy when reading or doing close work?
Never
Rarely
Occasionally
Often
Always
5. Do you lose concentration when reading or doing close work?
Never
Rarely
Occasionally
Often
Always
6. Do you have trouble remembering what you have read?
Never
Rarely
Occasionally
Often
Always
7. Do you have double vision when reading ordoing close work?
Never
Rarely
Occasionally
Often
Always
8. Do you see the words move, jump, swim orappear to float on the page when reading ordoing close work?
Never
Rarely
Occasionally
Often
Always
9. Do you feel like you read slowly?
Never
Rarely
Occasionally
Often
Always
10. Do your eyes ever hurt when reading or doing close work?
Never
Rarely
Occasionally
Often
Always
11. Do your eyes ever feel sore when reading or doing close work?
Never
Rarely
Occasionally
Often
Always
12. Do you feel a "pulling" feeling around your eyes when reading or doing close work?
Never
Rarely
Occasionally
Often
Always
13. Do you notice the words blurring or coming in and out of focus when reading or doing close work?
Never
Rarely
Occasionally
Often
Always
14. Do you lose your place while reading or doing close work?
Never
Rarely
Occasionally
Often
Always
15. Do you have to re-read the same line of words when reading?
Never
Rarely
Occasionally
Often
Always
Calculation
Email
example@example.com
View Results
These questions are based on the validated survey used in the Convergence Insufficiency Treatment Trial research, a multi-center clinical trial funded by the National Eye Institute (NEI). If you've had a concussion or brain injury, the Brain Injury Visual Symptoms Survey is recommended instead. Please contact our office to obtain.
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