Do your eyes feel tired when reading or doing close work?* Never Rarely Some Often Always Do your eyes feel uncomfortable when reading or doing close work?* Never Rarely Some Often Always Do you have headaches when reading or doing close work?* Never Rarely Some Often Always Do you feel sleepy when reading or doing close work?* Never Rarely Some Often Always Do you lose concentration when reading or doing close work?* Never Rarely Some Often Always Do you have trouble remembering what you have read?* Never Rarely Some Often Always Do you see double (two) when reading or doing close work?* Never Rarely Some Often Always Do you see the words move, jump or swim on the page when reading or doing close work?* Never Rarely Some Often Always Do you feel like you read slowly?* Never Rarely Some Often Always Do your eyes ever hurt when reading or doing close work?* Never Rarely Some Often Always Do your eyes ever feel sore when reading or doing close work?* Never Rarely Some Often Always Do you feel a “pulling” feeling around your eyes when reading or doing close work?* Never Rarely Some Often Always Do you notice the words blurring or coming in and out of focus when reading or doing close work?* Never Rarely Some Often Always Do you lose your place while reading or doing close work?* Never Rarely Some Often Always Do you have to re-read the same line of words when reading?* Never Rarely Some Often Always NamePhone