CONVERGENCE INSUFFICIENCY SYMPTOM SURVEY (CISS)

Patient 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?
      Never
      Not Very Often
      Sometimes
      Fairly Often
      Always
      0
      1
      2
      3
      4
    • 2. Do your eyes feel uncomfortable when reading or doing close work?
      Never
      Not Very Often
      Sometimes
      Fairly Often
      Always
      0
      1
      2
      3
      4
    • 3. Do you have headaches when reading or doing close work?
      Never
      Not Very Often
      Sometimes
      Fairly Often
      Always
      0
      1
      2
      3
      4
    • 4. Do you feel sleepy when reading or doing close work?
      Never
      Not Very Often
      Sometimes
      Fairly Often
      Always
      0
      1
      2
      3
      4
    • 5. Do you lose concentration when reading or doing close work?
      Never
      Not Very Often
      Sometimes
      Fairly Often
      Always
      0
      1
      2
      3
      4
    • 6. Do you have trouble remembering what you have read?
      Never
      Not Very Often
      Sometimes
      Fairly Often
      Always
      0
      1
      2
      3
      4
    • 7. Do you see the words move, jump, swim or appear to float on the page when reading or doing close work?
      Never
      Not Very Often
      Sometimes
      Fairly Often
      Always
      0
      1
      2
      3
      4
    • 8. Do you see the words move, jump, swim or appear to float on the page when reading or doing close work?
      Never
      Not Very Often
      Sometimes
      Fairly Often
      Always
      0
      1
      2
      3
      4
    • 9. Do you feel like your read slowly?
      Never
      Not Very Often
      Sometimes
      Fairly Often
      Always
      0
      1
      2
      3
      4
    • 10. Do your eyes ever hurt when reading or doing close work?
      Never
      Not Very Often
      Sometimes
      Fairly Often
      Always
      0
      1
      2
      3
      4
    • 11. Do your eyes ever feel sore when reading or doing close work?
      Never
      Not Very Often
      Sometimes
      Fairly Often
      Always
      0
      1
      2
      3
      4
    • 12. Do you feel a "pulling" feeling around your eyes when reading or doing close work?
      Never
      Not Very Often
      Sometimes
      Fairly Often
      Always
      0
      1
      2
      3
      4
0
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Thank You For Taking This Survey
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