1. Do your eyes feel tired when reading or doing close work?
Choose a response
Never
Infrequently
Sometimes
Fairly Often
Always
2. Do your eyes feel uncomfortable when reading or doing close work?
Choose a response
Never
Infrequently
Sometimes
Fairly Often
Always
3. Do you have headaches when reading or doing close work?
Choose a response
Never
Infrequently
Sometimes
Fairly Often
Always
4. Do you feel sleepy when reading or doing close work?
Choose a response
Never
Infrequently
Sometimes
Fairly Often
Always
5. Do you lose concentration when reading or doing close work?
Choose a response
Never
Infrequently
Sometimes
Fairly Often
Always
6. Do you have trouble remembering what you have read?
Choose a response
Never
Infrequently
Sometimes
Fairly Often
Always
7. Do you have double vision when reading or doing close work?
Choose a response
Never
Infrequently
Sometimes
Fairly Often
Always
8. Do you see the words move, jump, swim, or appear to float on the page when reading or doing close work?
Choose a response
Never
Infrequently
Sometimes
Fairly Often
Always
9. Do you feel like you read slowly?
Choose a response
Never
Infrequently
Sometimes
Fairly Often
Always
10. Do your eyes ever hurt when reading or doing close work?
Choose a response
Never
Infrequently
Sometimes
Fairly Often
Always
11. Do your eyes ever feel sore when reading or doing close work?
Choose a response
Never
Infrequently
Sometimes
Fairly Often
Always
12. Do you feel a ‘pulling’ feeling around your eyes when reading or doing close work?
Choose a response
Never
Infrequently
Sometimes
Fairly Often
Always
13. Do you notice the words blurring or coming in and out of focus when reading or doing close work?
Choose a response
Never
Infrequently
Sometimes
Fairly Often
Always
14. Do you lose your place while reading or doing close work?
Choose a response
Never
Infrequently
Sometimes
Fairly Often
Always
15. Do you have to re-read the same line of words when reading?
Choose a response
Never
Infrequently
Sometimes
Fairly Often
Always
Calculate Score
Reference
Borsting EJ, et al. Validity and Reliability of the Revised Convergence Insufficiency Symptom Survey in Children Aged 9 to 18 Years. Optom Vis Sci. 2003;80(12):832–838.