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Symptom Survey

Functional Vision Self Assessment

This survey, known as the Convergence Insufficiency Symptom Survey (CISS), has been used in multiple research studies and has been confirmed to be an effective in tool helping to identify those with visual symptoms and those who likely struggle with vision problems that can be treated!

Instructions

Download and print the survey to fill out on your own. Add up your score as indicated at the bottom of the paper. If you score 16 or above, please call us to schedule an appointment to discuss your results. This could indicate a possible underlying visual dysfunction.