Name

First Last

Appointment Date

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

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

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

Do you have headaches when reading or doing close work?

Do you feel sleepy when reading or doing close work?

Do you lose concentration when reading or doing close work?

Do you have trouble remembering what you have read?

Do you feel like you read slowly?

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

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

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

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

Do you feel a “pulling” feeling around your eyes when reading or doing close work?

Do you notice the words blurring or coming in and out of focus when reading or doing close work?

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

Do you have to re-read the same line of words when reading?

Convergence Insufficiency Signs and Symptoms Checklist (CISS)

EYEcenter Optometric