Screening Test & Questionnaire

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.

Screening Test

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

  1. Yes, very uncomfortable
  2. Not uncomfortable, but unstable
  3. 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.

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  • NeverNot Very OftenSometimesFairly OftenAlways
  • NeverNot Very OftenSometimesFairly OftenAlways
  • NeverNot Very OftenSometimesFairly OftenAlways
  • NeverNot Very OftenSometimesFairly OftenAlways
  • NeverNot Very OftenSometimesFairly OftenAlways
  • NeverNot Very OftenSometimesFairly OftenAlways
  • NeverNot Very OftenSometimesFairly OftenAlways
  • NeverNot Very OftenSometimesFairly OftenAlways
  • NeverNot Very OftenSometimesFairly OftenAlways
  • NeverNot Very OftenSometimesFairly OftenAlways
  • NeverNot Very OftenSometimesFairly OftenAlways