Convergence Insufficiency Symptom Survey Name*Date Date Format: MM slash DD slash YYYY Phone*Email* Instructions: Please answer the following questions about how your eyes feel when reading or doing close work. Do your eyes feel tired when reading or doing close work?Never(not very often) InfrequentlySometimesFairly oftenAlwaysDo your eyes feel uncomfortable when reading or doing close work?Never(not very often) InfrequentlySometimesFairly oftenAlwaysDo you have headaches when reading or doing close work?Never(not very often) InfrequentlySometimesFairly oftenAlwaysDo you feel sleepy when reading or doing close work?Never(not very often) InfrequentlySometimesFairly oftenAlwaysDo you lose concentration when reading or doing close work?Never(not very often) InfrequentlySometimesFairly oftenAlwaysDo you have trouble remembering what you have read?Never(not very often) InfrequentlySometimesFairly oftenAlwaysDo you have double vision when reading or doing close work?Never(not very often) InfrequentlySometimesFairly oftenAlwaysDo you see the words move, jump, swim or appear to float on the page when reading or doing close work?Never(not very often) InfrequentlySometimesFairly oftenAlwaysDo you feel like you read slowly?Never(not very often) InfrequentlySometimesFairly oftenAlwaysDo your eyes ever hurt when reading or doing close work?Never(not very often) InfrequentlySometimesFairly oftenAlwaysDo your eyes ever feel sore when reading or doing close work?Never(not very often) InfrequentlySometimesFairly oftenAlwaysDo you feel a "pulling" feeling around your eyes when reading or doing close work?Never(not very often) InfrequentlySometimesFairly oftenAlwaysDo you notice the words blurring or coming in and out of focus when reading or doing close work?Never(not very often) InfrequentlySometimesFairly oftenAlwaysDo you lose your place while reading or doing close work?Never(not very often) InfrequentlySometimesFairly oftenAlwaysDo you have to re-read the same line of words when reading?Never(not very often) InfrequentlySometimesFairly oftenAlwaysPhoneThis field is for validation purposes and should be left unchanged.