Convergence Insufficiency Symptom Survey

Name

Location / Branch

Date


SYMPTOMS (Please fill this out with your child)


Use the following scale to choose the most appropriate number for each situation:

0 - Never
1 - Infrequently
2 - Sometimes
3 - Fairly Often
4 - Always

***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 have double vision when reading or doing close work?
Do you see the words move, jump, swim or appear to float on the page?
Do you feel like you read slowly?
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 reread the same line of words when reading?
Total Score:
You are missing required questions.
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Eye Therapy Vision Rehabilitation Center
Lantern Lane Location

12512 Memorial Dr. Ste A
​​​​​​​Houston, TX 77024
Eye Therapy Vision Rehabilitation Center
Sealy Location

1614 Highway 36
​​​​​​​Sealy, TX 77474
Eye Therapy Vision Rehabilitation Center
Energy Corridor Location

14634 Memorial Drive
​​​​​​​Houston, TX 77079
At the corner of Dairy Ashford and Memorial Dr.
Eye Therapy Vision Rehabilitation Center
Pasadena Location

132 Southmore Ave, Ste A
​​​​​​​Pasadena, TX 77502

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Hours Of Operation

Eye Therapy Vision Rehabilitation Center
Lantern Lane Location
  • Monday Closed
  • Tuesday 9:30 AM - 5:00 PM
  • Wednesday 9:30 AM - 5:00 PM
  • Thursday 9:30 AM - 5:00 PM
  • Friday 9:30 AM - 4:00 PM
  • Saturday Closed
  • Sunday Closed
Eye Therapy Vision Rehabilitation Center
Energy Corridor Location
  • Monday 9:30 AM - 1:00 PM
  • Tuesday 9:30 AM - 5:00 PM
  • Wednesday 9:30 AM - 5:00 PM
  • Thursday 9:30 AM - 5:00 PM
  • Friday 9:30 AM - 5:00 PM
  • Saturday Closed
  • Sunday Closed
​​​​​​​*Closed for lunch every day from 1-2pm
Eye Therapy Vision Rehabilitation Center
Pasadena Location
  • Monday Closed
  • Tuesday 10:00 AM - 6:00 PM
  • Wednesday 10:00 AM - 6:00 PM
  • Thursday Closed
  • Friday 10:00 AM - 6:00 PM
  • Saturday 10:00 AM - 3:00 PM
  • Sunday Closed
Eye Therapy Vision Rehabilitation Center
Sealy Location
  • Monday 10:00 AM - 5:00 PM
  • Tuesday 10:00 AM - 5:00 PM
  • Wednesday 10:00 AM - 5:00 PM
  • Thursday Closed
  • Friday 10:00 AM - 1:00 PM
  • Saturday Closed
  • Sunday Closed
​​​​​​​*Closed for lunch every day from 1-2pm

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