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.

  • 0 = Never

  • 1 = Infrequently (not very often)

  • 2 = Sometimes

  • 3 = Fairly often

  • 4 = Always

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

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

3. Do you have headaches when reading or doing close work?​​​​​​​

4. Do you feel sleepy when reading or doing close work?​​​​​​​

5. Do you lose concentration when reading or doing close work?​​​​​​​

6. Do you have trouble remembering what you have read?​​​​​​​

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

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

9. Do you feel like you read slowly?​​​​​​​

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

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

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?​​​​​​​

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

15. Do you have to re‐read the same line of words when reading?​​​​​​​

Your Score:

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: (612) 200-3286