Self Assessment November 24, 2017 Welcome to your Self Assessment Please answer the following questions about how your eyes feel when reading or doing close work. This survey is not a substitute for consulting a physician, and does not provide diagnoses. Choose as follows: 0 = Never, 1 = Infrequently, 2 = Sometimes, 3 = Fairly Often, 4 = Always Do your eyes feel tired when reading or doing close work? 0 1 2 3 4 None Do your eyes feel uncomfortable when reading or doing close work? 0 1 2 3 4 None Do you have headaches when reading or doing close work? 0 1 2 3 4 None Do you feel sleepy when reading or doing close work? 0 1 2 3 4 None Do you lose concentration when reading or doing close work? 0 1 2 3 4 None Do you have trouble remembering what you read? 0 1 2 3 4 None Do you have double vision when reading or doing close work? 0 1 2 3 4 None Do you see the words move, jump, swim, or appear to float on the page? 0 1 2 3 4 None Do your eyes feel like you read slowly? 0 1 2 3 4 None Do your eyes ever hurt when reading or doing close work? 0 1 2 3 4 None Do your eyes ever feel sore when reading or doing close work? 0 1 2 3 4 None Do you feel a pulling feeling around your eyes when reading or doing close work? 0 1 2 3 4 None Do you notice the words blurring or coming in and out of focus when reading or doing close work? 0 1 2 3 4 None Do you lose your place while reading or doing close work? 0 1 2 3 4 None Do you have to reread the same line of words when reading? 0 1 2 3 4 None Time's up Share 0
