Symptom Checklist

Name

First Last

Date of Birth

Phone

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

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

NOTE: If the patient is a child, please read the instructions and then each item exactly as written. If patient responds with "yes" please qualify with frequency choices. Do not give examples.

Untitled Survey Field

	Never	(Not Very Often) Infrequently	Sometimes	Fairly Often	Always
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 when reading or doing close work?
Do yo 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 when reading or doing close work?
Do you have to reread the same line of words when reading?

Symptom Checklist

Symptom Survey

Sibley Eye Care

Northwest Iowa Vision Therapy