Convergence Insufficiency Symptom Survey

A validated 15-item self-assessment for symptoms related to convergence insufficiency (CI) and near-vision disorders.

Clinical threshold: score ≥ 21 | Rate each symptom 0 (Never) – 4 (Always)

Your CITT Result

0

Your results have been submitted to London Vision Training Clinic in accordance with PHIPA and PIPEDA. A clinician will follow up with you. You may request access to or correction of your information at any time by contacting our office.

Clinician instructions: Read the following subject instructions and then each item exactly as written. If subject responds with "yes" — please qualify with frequency choices. Do not give examples.

Subject instructions: Please answer the following questions about how your eyes feel when reading or doing close work.

Your Contact Information

Full Name *

Email Address

Phone Number

# Symptom (when reading or doing close work)	0 Never	1 Infrequently	2 Sometimes	3 Fairly often	4 Always

Live Score

0

Progress

0 / 15 answered

Answer questions to see your prediction

🔒 Privacy Statement PHIPA & PIPEDA — click to expand ▼

Who collects your information

London Vision Training Clinic ("the Clinic") collects the personal health information on this form under the authority of PHIPA and in accordance with PIPEDA.

What we collect

Contact details you provide (name, email, phone number)
Your responses to the 15-item Convergence Insufficiency Symptom Survey (CISS) and your total score

Purpose of collection

To assess symptoms related to convergence insufficiency and near-vision disorders
To allow a clinician to follow up with you regarding your results
To support continuity of care if you become a patient of the Clinic

How we protect your information

Your data is transmitted over an encrypted (HTTPS/TLS) connection and stored on secure servers accessible only to authorised Clinic staff. We do not sell, trade, or share your personal health information with third parties except as required or permitted by law.

Retention

Survey responses are retained for a minimum of 10 years in accordance with Ontario optometry record-keeping requirements, after which they are securely destroyed.

Your rights

You have the right to access or correct your personal health information held by the Clinic.
You may withdraw consent at any time by contacting us; however, withdrawal may limit our ability to provide care.
Complaints may be directed to the Information & Privacy Commissioner of Ontario.

Privacy contact

London Vision Training Clinic — Privacy Officer
106-557 Southdale Road East, London ON, N6E 1A2
admin@londonvision.ca | (519) 204-7230