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Chapter 1 Appendix
Convergence Insufficiency - Symptom Questionnaire V-15
Name _____________________________________ DATE __/__/__
Subject instructions: Please answer the following questions about how your eyes feel when reading or doing close work. Choose your response from the card that I have just handed you.
| No. | Convergence Insufficiency - Symptom Questionnaire V-15 | Never | Infrequently | Sometimes | Fairly often | Always |
|---|---|---|---|---|---|---|
| 1. | Do your eyes feel tired when reading or doing close work? | |||||
| 2. | Do your eyes feel uncomfortable when reading or doing close work? | |||||
| 3. | Do you have headaches when reading or doing close work? | |||||
| 4. | Do you feel sleepy when reading or doing close work? | |||||
| 5. | Do you lose concentration when reading or doing close work? | |||||
| 6. | Do you have trouble remembering what you have read? | |||||
| 7. | Do you have double vision when reading or doing close work? | |||||
| 8. | Do you see the words move, jump, swim or appear to float on the page when reading or doing close work? | |||||
| 9. | Do you feel like you read slowly? | |||||
| 10. | Do your eyes ever hurt when reading or doing close work? | |||||
| 11. | Do your eyes ever feel sore when reading or doing close work? | |||||
| 12. | Do you feel a "pulling" feeling around your eyes when reading or doing close work? | |||||
| 13. | Do you notice the words blurring or coming in and out of focus when reading or doing close work? | |||||
| 14. | Do you lose your place while reading or doing close work? | |||||
| 15. | Do you have to re-read the same line of words when reading? | |||||
| TOTAL Xs in each column | x 0 | x 1 | x 2 | x 3 | x 4 |
Score _____________
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