Step 1

Symptom Survey

Step 2

Clinical Findings

Step 3

Diagnosis & Plan

Patient Symptom Intake

Convergence Insufficiency Symptom Survey (CISS) & History

Patient Information

Patient Age

Classification

Adult (≥18)

Child (<18)

Instructions: Rate how often each symptom occurs during reading or close work. The CISS is a validated CI instrument — a high score means "proceed to full workup," not "likely CI." A low score is genuinely reassuring.

Do your eyes feel tired when reading or doing close work?

Never

Infrequently

Sometimes

Fairly Often

Always

Do your eyes feel uncomfortable when reading or doing close work?

Never

Infrequently

Sometimes

Fairly Often

Always

Do you have headaches when reading or doing close work?

Never

Infrequently

Sometimes

Fairly Often

Always

Do you feel sleepy when reading or doing close work?

Never

Infrequently

Sometimes

Fairly Often

Always

Do you lose concentration when reading or doing close work?

Never

Infrequently

Sometimes

Fairly Often

Always

Do you have trouble remembering what you have read?

Never

Infrequently

Sometimes

Fairly Often

Always

Do you have double vision when reading or doing close work?

Never

Infrequently

Sometimes

Fairly Often

Always

Do you see the words move, jump, swim, or appear to float on the page when reading?

Never

Infrequently

Sometimes

Fairly Often

Always

Do you feel like you read slowly?

Never

Infrequently

Sometimes

Fairly Often

Always

Do your eyes ever hurt when reading or doing close work?

Never

Infrequently

Sometimes

Fairly Often

Always

Do your eyes ever feel sore when reading or doing close work?

Never

Infrequently

Sometimes

Fairly Often

Always

Do you feel a 'pulling' feeling around your eyes when reading or doing close work?

Never

Infrequently

Sometimes

Fairly Often

Always

Do you notice the words blurring or coming in and out of focus when reading?

Never

Infrequently

Sometimes

Fairly Often

Always

Do you lose your place while reading or doing close work?

Never

Infrequently

Sometimes

Fairly Often

Always

Do you have to re-read the same line of words when reading?

Never

Infrequently

Sometimes

Fairly Often

Always

Additional Symptom Screen

High-yield domains the CISS doesn't cover. Check all that apply.

Dizziness / light-headedness / unsteadiness / "floaty" feeling

Motion sensitivity (supermarket, scrolling, car sickness)

Photophobia / glare / fluorescent / screen brightness intolerance

Neck, shoulder, jaw tension; head tilt or turn; leaning close

Distance symptoms (blur after near work, night driving, signage)

Depth/spatial: clumsiness, missing catches, judging stairs, parking

Skipping lines, losing place, using a finger, re-reading, omitting words

Closing or covering one eye, squinting, eye rubbing

Avoidance behaviours (often the loudest signal in children)

Symptom Latency: How many minutes of reading/screen work before symptoms start?

More sensitive to change than frequency — it's what patients notice improving.

Clinical History

Concussion / whiplash / head injury (including old and "minor")

Migraine / headache history (biggest confounder for "headaches with near work")

ADHD / Dyslexia / Autism / Learning diagnoses

CISS v15 - Borsting E, et al. Optom Vis Sci. 2003;80(12):832-838