Parent Symptom Survey
Symptom Survey (CISS)
(for Patients ≥8 Years of Age)
Name _______________________________________ Date ______________________
Please answer the following questions about how your eyes feel when reading or
doing close work. (For patients ≤12 years of age, the intern/doctor should read the
question to the patient.)
Symptom: Never Infrequently – Sometimes Often – Fairly 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 that 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 have a “pulling” feeling
around your eyes when reading or
doing close work?
13. Do words blur or come 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 reread the same line
of words when reading?
Score 0 for Never; 1 for Infrequently; 2 for Sometimes; 3 for Fairly Often; and 4 for Always.
TOTAL SCORE: __________
This Survey was developed by the Convergence Insufficiency Research Group.
Teacher Symptom Survey
Teacher Questionnaire
To the teacher of ___________________Grade_______School__________________
The child named above is receiving vision care at our center. In order to address the
impact of vision problems on classroom performance, we would like your observations of this child’s behavior in school. It has been shown that the teacher is frequently the best observer for identifying vision problems that tend to interfere with
school work. The following checklist identifies many of the observable clues and
symptoms that are observed in a child with a vision problem. Please read through this
list and check items that you have noted to occur in this child’s case, along with the
frequency.
Symptom: Never – Infrequently – Sometimes – Fairly Always
1. Does the child report that his/her
eyes feel tired when reading or
doing close work?
2. Does the child report that his/her
eyes feel uncomfortable when
reading or doing close work?
3. Does the child report headaches
when reading or doing close work?
4. Does the child report that he/she
feels sleepy when reading or doing
close work?
5. Does the child report that he/she
loses concentration when reading or
doing close work?
6. Does the child have trouble
remembering what he/she has read?
7. Does the child report double vision
when reading or doing close work?
8. Does the child report that he/she
sees the words move, jump, swim, or
appear to float on the page when
reading or doing close work?
9. Does the child read slowly?
10. Does the child report that his/her
eyes ever hurt when reading or doing
close work?
11. Does the child report that his/her
eyes ever feel sore when reading or
doing close work?
12. Does the child report a “pulling”
feeling around his/her eyes when
reading or doing close work?
13. Does the child report that words blur
or come in and out of focus when
reading or doing close work?
14. Does the child lose his/her place
while reading or doing close work?
15. Does the child have to reread the
same line of words when reading?
16. Does the child make reversal errors
when reading (was for saw, on for
no) or writing (b for d)?
17. Does the child transpose letters or
numbers (21 for 12)?
18. Does the child have difficulty copying
written material?
19. Does the child have poor printing or
handwriting?
20. Does the child avoid reading?
21. Does the child have difficulty finishing
school assignments in a timely
manner?Please comment on the following:
1. Does this child have any academic problems? ___Yes ___No
If so, please explain (e.g., subject material, behavior, etc.) _______________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
2. Is (s)he in the top third, middle third, or lower third of his/her class? __________
3. How does academic achievement compare with potential? ____________________
________________________________________________________________________
________________________________________________________________________
4. At what grade level does this child read? ___________________________________
5. Please check any areas of difficulty:
__ Vocabulary __ Word Recognition __ OralReading
__ Reading Rate __ Interpretation __ SilentReading
__ Attention __ Comprehension __ Memory
__ Math Skills __ Spelling __ Written Work
6. Do you feel that there are any factors that may be interfering with academic
achievement?____________________________________________________________
________________________________________________________________________
________________________________________________________________________
22. Does the child misalign digits or
columns when doing math
assignments?
23. Does the child seem to be clumsy or
knock things over?
24. Does the child overlook small details
(reads beak for break) or misread
math symbols (– for +)?
25. Does the child have a short attention
span or is he/she easily distractible
when reading or studying?7. Any other observations and/or comments which you feel may be beneficial to us
would be appreciated. ___________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
May we contact you if further information is required? If so, please provide a telephone number at which you can be reached.
Teacher _____________________________________ Phone _____________________
School Name ____________________________________________________________
Address ________________________________________________________________
City______________________________________State__________ Zip __________
Signature _________________________________________ Date _________________
I hereby give my consent to release the above information
Parent or Guardian Signature ____________________________ Date _____________
