CONVERGENCE INSUFFICIENCY SYMPTOM SURVEY (CISS)

Patient Instructions

Please answer the following questions about how your eyes feel when reading or doing close work.

1. • 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