Visual Comfort Survey

This short survey helps identify symptoms associated with teaming and/or focusing visual system issues. Please answer honestly and to the best of your ability.

MM slash DD slash YYYY
Instructions: 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?(Required)
2. Do your eyes feel uncomfortable when reading or doing close work?(Required)
3. Do you have headaches when reading or doing close work?(Required)
4. Do you feel sleepy when reading or doing close work?(Required)
5. Do you lose concentration when reading or doing close work?(Required)
6. Do you have trouble remembering what you have read?(Required)
7. Do you have double vision when reading or doing close work?(Required)
8. Do you see the words move, jump, swim or appear to float on the page when reading or doing close work?(Required)
9. Do you feel like you read slowly?(Required)
10. Do your eyes ever hurt when reading or doing close work?(Required)
11. Do your eyes ever feel sore when reading or doing close work?(Required)
12. Do you feel a “pulling” feeling around your eyes when reading or doing close work?
13. Do you notice the words blurring or coming in and out of focus when reading or doing close work?(Required)
14. Do you lose your place while reading or doing close work?(Required)

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 our office and schedule an examination.

This form was created for evaluating convergence insufficiency symptoms.

Borsting EJ, Rouse MW, Mitchell GL, Scheiman M, Cotter SA, Cooper J, Kulp MT, London R; Convergence Insufficiency Treatment Trial Group. Validity and reliability of the revised convergence insufficiency symptom survey in children aged 9 to 18 years. Optom Vis Sci. 2003 Dec;80(12):832-8. doi: 10.1097/00006324-200312000-00014. PMID: 14688547.