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Employed
Fulltime Student
Parttime Student
Is your child especially afraid of Doctors: Yes No
Neuro/psych eval: Yes No
Occupational Therapy eval? Yes No
Poor Vision: Child Family
Strabismus: Child Family
Amblyopia: Child Family
Cancer: Child Family
Epilepsy/Seizures: Child Family
Learning issue: Child Family
Blindness: Child Family
Yes No
Forceps / Vacuum
Anesthesia
toxemia
trauma
use of alcohol
injury by fall
smoking
use of drugs
severe illness
prescription medication
little obstetrical care
other
biological
adopted
foster
Yes
No
Headaches
Blurred Vision
Double Vision
Eyes "hurt" or "tired"
Nausea when doing visual tasks
Motion Sickness / Car Sickness
Frequent styes
Eyes itch
Eyes burn
Eyes tear
Eyes frequently reddened
Closing or covering one eye
Loses place while reading
Poor reading comprehension
LWhen reading, letters/words appear to move or float around
Loses attention easily
In
Out
Up
Down
Right
Left
Both
Up close
In the distance
To the left
To the right
Forehead
Right side
Left side
Back of head
Top of head
Face
What Types Of Professional Care Have You Received or Are Receiving Due To This Injury?
Score Each Behavior: Never=0 Seldom=1 Occasionally=2 Frequently=3 Always=4
If you experience any of the symptoms below, please check if the symptom was present before the injury or only after:
Glare
Eye ache
Itching
Redness Burning Light Sensitivity Tearing / Watery eyes Stinging Grittiness Dryness Mattering on your eyelids when you wake up in the morning Dry Mouth Eye lids swollen or red along the lash margin Night Driving Problems Burning in the morning Decreased contact lens wearing time Vision fluctuates from clear to blurry especially in the morning after reading, watching TV, computer use, or driving. Artificial Tear drops help but do not last long enough Do you take Omega-3 supplements daily? Do you use Visine or other "get the red out" drops? How often? Have you ever been prescribed RESTASIS eye drops? Please do not hit submit until all applicable tabs have been completed. Please do not hit submit until all applicable tabs have been completed. Reading and Computer Symptom Checklist CONVERGENCE INSUFFICIENCY SYMPTOM SURVEY (CISS) 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. Never=0 Infrequently=1 Sometimes=2 Fairly Often=3 Always=4 1. Do your eyes feel tired when reading or doing close work? 0 1 2 3 4 2. Do your eyes feel uncomfortable when reading or doing close work? 0 1 2 3 4 3. Do you have headaches when reading or doing close work? 0 1 2 3 4 4. Do you feel sleepy when reading or doing close work? 0 1 2 3 4 5. Do you lose concentration when reading or doing close work? 0 1 2 3 4 6. Do you have trouble remembering what you have read? 0 1 2 3 4 7. Do you ahve double vision when reading or doing close work? 0 1 2 3 4 8. Do you see the words move, jump, swim or appear to float on the page when reading or doing close work? 0 1 2 3 4 9. Do you feel like you read slowly? 0 1 2 3 4 10. Do your eyes ever hurt when reading or doing close work? 0 1 2 3 4 11. Do your eyes ever feel sore when reading or doing close work? 0 1 2 3 4 12. Do you feel a 'pulling' feeling around your eyes when reading or doing close work? 0 1 2 3 4 13. Do you notice the words blurring or coming in and out of focus when reading or doing close work? 0 1 2 3 4 14. Do you lose your place when reading or doing close work? 0 1 2 3 4 15. Do you have to reread the same line of words when reading? 0 1 2 3 4 Check All That Apply: Tendency to close or cover one eye Reverses or forgets letters, numbers or words Head tilt or movement Confuses similar looking words Poor reading comprehension Difficulty recognizing the same word in the next paragraph Head too close to the paper while reading or writing Poor spelling Difficulty tracking moving objects, balls, etc... Poor visual-motor(eye-hand/foot) coordination Writing is crooked or poorly spaced Confuses right and left Misalignment of digits or columns of numbers Difficulty following a sequence of directions Errors copying from chalkboard, computer or book Whispers when reading silently Avoids near work or reading Comprehension decreases over time Difficulty completing assignments in time allotted Does not visualize Please do not hit submit until all applicable tabs have been completed. Please do not hit submit until all applicable tabs have been completed. Dizziness And Motion Sensitivity Checklist Nausea, headache or dizziness when reading in the car even on a STRAIGHT road Nausea, headache or dizziness when sitting close to a movie screen or watching a train go by Hyper-sensitive to light (store lights seem bright, tend to wear sunglasses even on cloudy days) Frequent, sometimes daily, headache or 'pressure' in your head Nausea, headache, dizziness or spacey feeling when shopping or moving through crowds of people Unusual fear of heights Lose your place easily when reading Flickering lights bother you (light through trees when driving or fluorescents) Avoidance of driving because of car sickness Please do not hit submit until all applicable tabs have been completed. Submit Data
CONVERGENCE INSUFFICIENCY SYMPTOM SURVEY (CISS)
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.
Never=0 Infrequently=1 Sometimes=2 Fairly Often=3 Always=4
Check All That Apply:
Tendency to close or cover one eye
Reverses or forgets letters, numbers or words
Head tilt or movement
Confuses similar looking words
Difficulty recognizing the same word in the next paragraph
Head too close to the paper while reading or writing
Poor spelling
Difficulty tracking moving objects, balls, etc...
Poor visual-motor(eye-hand/foot) coordination
Writing is crooked or poorly spaced
Confuses right and left
Misalignment of digits or columns of numbers
Difficulty following a sequence of directions
Errors copying from chalkboard, computer or book
Whispers when reading silently
Avoids near work or reading
Comprehension decreases over time
Difficulty completing assignments in time allotted
Does not visualize
Nausea, headache or dizziness when reading in the car even on a STRAIGHT road
Nausea, headache or dizziness when sitting close to a movie screen or watching a train go by
Hyper-sensitive to light (store lights seem bright, tend to wear sunglasses even on cloudy days)
Frequent, sometimes daily, headache or 'pressure' in your head
Nausea, headache, dizziness or spacey feeling when shopping or moving through crowds of people
Unusual fear of heights
Lose your place easily when reading
Flickering lights bother you (light through trees when driving or fluorescents)
Avoidance of driving because of car sickness