Convergence Insufficiency Symptom Survey

Reference: Borsting EJ, Rouse Mw, Mitchell GL, et al and the CITT group. Validity and reliability of the revised convergence insufficiency symptom survey in children. Optometry and Vision Science 2003; 80(12):832‐838.

INSTRUCTIONS: Please answer the following questions about how your eyes feel when reading or doing close work. Please choose the answer that best describes how you feel for each line.

1. Do your eyes feel tired when reading or doing close work? Never Infrequently (not very often) Sometimes Fairly often Always

2. Do your eyes feel uncomfortable when reading or doing close work? Never Infrequently (not very often) Sometimes Fairly often Always

3. Do you have headaches when reading or doing close work? Never Infrequently (not very often) Sometimes Fairly often Always

4. Do you feel sleepy when reading or doing close work? Never Infrequently (not very often) Sometimes Fairly often Always

5. Do you lose concentration when reading or doing close work? Never Infrequently (not very often) Sometimes Fairly often Always

6. Do you have trouble remembering what you have read? Never Infrequently (not very often) Sometimes Fairly often Always

7. Do you have double vision when reading or doing close work? Never Infrequently (not very often) Sometimes Fairly often Always

8. Do you see the words move, jump, swim or appear to float on the page when reading or doing close work? Never Infrequently (not very often) Sometimes Fairly often Always

9. Do you feel like you read slowly? Never Infrequently (not very often) Sometimes Fairly often Always

10. Do your eyes ever hurt when reading or doing close work? Never Infrequently (not very often) Sometimes Fairly often Always

11. Do your eyes ever feel sore when reading or doing close work? Never Infrequently (not very often) Sometimes Fairly often Always

12. Do you feel a "pulling" feeling around your eyes when reading or doing close work? Never Infrequently (not very often) Sometimes Fairly often Always

13. Do you notice the words blurring or coming in and out of focus when reading or doing close work? Never Infrequently (not very often) Sometimes Fairly often Always

14. Do you lose your place while reading or doing close work? Never Infrequently (not very often) Sometimes Fairly often Always

15. Do you have to re‐read the same line of words when reading? Never Infrequently (not very often) Sometimes Fairly often Always

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Your Score: 0

Significant Scores: Children ≥ 16, Adults ≥ 21

If your score qualifies as significant, OR if you have not had an eye exam within the past year, please call the number listed below for a comprehensive vision exam.

Phone: (231) 591-2020, Fax: (231) 591-3991

1124 S State Street, MCO 101, Big Rapids, MI 49307-2738
Web: ferris.edu/UEC