Vision Symptom Survey

Symptom Survey

If you score more than a total of 15 to these questions, you may consider a binocular vision evaluation to understand the root cause of your symptoms

Do your eyes feel tired when reading or doing close work?

	0	1	2	3	4

0 is No, 4 is Yes

Do your eyes feel uncomfortable when reading or doing close work?

	0	1	2	3	4

0 is No, 4 is Yes

Do you have headaches when reading or doing close work?

	0	1	2	3	4

0 is No, 4 is Yes

Do you feel sleepy when reading or doing close work?

	0	1	2	3	4

0 is No, 4 is Yes

Do you lose concentration when reading or doing close work?

	0	1	2	3	4

0 is No, 4 is Yes

Do you have trouble remembering what you have read?

	0	1	2	3	4

0 is No, 4 is Yes

Do you have double vision when reading or doing close work?

	0	1	2	3	4

0 is No, 4 is Yes

Do you see the words move, jump, swim, or appear to float on the page when reading or doing close work?

	0	1	2	3	4

0 is No, 4 is Yes

Do you feel like you read slowly?

	0	1	2	3	4

0 is No, 4 is Yes

Do your eyes ever hurt when reading or doing close work?

	0	1	2	3	4

0 is No, 4 is Yes

Do your eyes ever feel sore when reading or doing close work?

	0	1	2	3	4

0 is No, 4 is Yes

Do you feel a “pulling” feeling around your eyes when reading or doing close work?

	0	1	2	3	4

0 is No, 4 is Yes

Do you notice the words blurring or coming in and out of focus when reading or doing close work?

	0	1	2	3	4

0 is No, 4 is Yes

Do you lose your place while reading or doing close work?

	0	1	2	3	4

0 is No, 4 is Yes

Do you have to re-read the same line of words when reading?

	0	1	2	3	4

0 is No, 4 is Yes

Test Results

If you score more than 15, you may consider a binocular vision evaluation to understand the root cause of your symptoms.
Total Score
Should be Empty:

Symptom Survey

Test Results