Screening Test & Questionnaire

Screening Test

This screening grid and brief questionnaire may be used to help uncover possible visual issues and eye-teaming instability. Used together, they will allow you to quickly determine, with reasonable accuracy, whether a therapeutic glasses prescription and/or Vision Therapy will be beneficial.

Procedure

Look directly at the X in the middle of the grid (do not move your eyes). Does this pattern seem to move, shake, change colour or cause negative symptoms for you?

Common Responses

Yes, very uncomfortable
Not uncomfortable, but unstable
No, it looks fine

A negative or uncomfortable reaction to viewing the grid is a strong indicator that an individual would benefit from referral and further assessment. This test requires minimal vestibular, cervical or cognitive input – making the findings primarily visual.

To refer yourself or a client to our office, please contact us.

Credit: Dr. Merrill D. Bowan, OD

Following use of the above screening grid, please complete the brief questionnaire below.

Convergence Insufficiency Symptom Survey

A total score of 22 points or higher is a strong indicator that referral is prudent. Pressing submit at the bottom of the questionnaire will automatically tally your score.

Do your eyes feel tired when reading or doing close work?*
Never Not Very Often Sometimes Fairly Often Always
Do your eyes feel uncomfortable when reading or doing close work?*
Never Not Very Often Sometimes Fairly Often Always
Do you have headaches when reading or doing close work?*
Never Not Very Often Sometimes Fairly Often Always
Do you feel sleepy when reading or doing close work?*
Never Not Very Often Sometimes Fairly Often Always
Do you lose concentration when reading or doing close work?*
Never Not Very Often Sometimes Fairly Often Always
Do you have trouble remembering what you read?*
Never Not Very Often Sometimes Fairly Often Always
Do you have double vision when reading or doing close work?*
Never Not Very Often Sometimes Fairly Often Always
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
Do you feel like you read slowly?*
Never Not Very Often Sometimes Fairly Often Always
Do your eyes ever hurt when reading or doing close work?*
Never Not Very Often Sometimes Fairly Often Always
Do your eyes feel sore when reading or doing close work?*
Never Not Very Often Sometimes Fairly Often Always
Do you feel “pulling” feeling around your eyes when reading or doing close work?*
Never Not Very Often Sometimes Fairly Often Always
Do you notice the words blurring or coming in and out of focus when reading or doing close work?*
Never Not Very Often Sometimes Fairly Often Always
Do you lose your place while reading or doing close work?*
Never Not Very Often Sometimes Fairly Often Always
Do you have to reread the same line of words when reading?*
Never Not Very Often Sometimes Fairly Often Always
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