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Shop
About Us
Our Clinic
Our Products
Our Team
Eye Health
Amblyopia
Astigmatism
Blepharitis
Cataracts
Computer Vision Syndrome
Diabetes
Dry Eye
Eye Allergies
Floaters And Flashes
Glaucoma
Hyperopia
Macular Degeneration
Melanoma
Myopia
Presbyopia
Strabismus
Symptoms
Services
Eye Examination
Diagnostic Equipment
Evaluating Your Frames
Choosing Your Contact Lenses
Dry Eyes
Myopia Management
Vision Therapy
Resources
Brands
E-Books
OHIP
Insurance
Blogs
Shipping Policy
Terms and Conditions
Book Appointment
Contact Us
Shop
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
Calculate Score
0
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Thank You For Taking This Survey
YOUR Score =
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