Visual Skills Screening
Convergence Insufficiency Symptom Survey
This survey was developed as part of a multi-center clinical trial o f the efficacy of vision therapy, supported by the National Institutes of Health. For the ages of 9-18, the items were validated against actual clinical data. The scientific reference for the paper where the questionnaire appears is at the bottom of the survey.
By filing this out, you warrant that you are providing truthful information, and that you agree to hold Gemstone Foundation harmless for any misstatement or other adverse action that may result from your interaction with us.
In turn, we promise to send you an evaluation of your responses, with a recommendation either to seek an opinion from your eye care professional or proceed with the Gemstone program or do nothing – your symptoms do not indicate a problem with convergence or related visual skills.
When you are finished, please email the form to [it would be terrific if we can have them fill it out online and press a button to send to us].
Email the form to us at firstname.lastname@example.org
You may also fax the form to us at (510) 243-8702.