Five Minute Cover Test - Dr. Clayton Y. Gushiken

Do you experience: Dizziness, Nausea, Headache, Neck Ache, Anxiety, Sensitivity to Light? Are these symptoms caused by your vision?
This easy, five-minute test may be the proof you need.

Name *

First

Last

Part 1: BEFORE

Which 2 symptoms are the most bothersome to you at this moment? Rate each symptom from 1-10, where 10 is the most severe and 1 is the least.

Dizziness (before test)

Selected Value: 1

Nausea (before test)

Selected Value: 1

Headache (before test)

Selected Value: 1

Neck Ache (before test)

Selected Value: 1

Anxiety (before test)

Selected Value: 1

Sensitivity to Light (before test)

Selected Value: 1

Part 2: The 5 Minute Test

1. Set a timing device (your phone, kitchen timer, etc.) for 5 minutes. If you have glasses or contact lenses that you normally wear, wear them for this test.

2. You will need to cover one eye for this test. To determine which eye to cover, tilt your head towards each shoulder. One side should feel easier than the other.

3. When you find the more comfortable side, cover the “high” eye with your hand. (Your “high” eye is the eye closest to the ceiling.)

4.Now, return your head to the upright position.

5. Keep both eyes open, but cover the “high” eye with your hand.

6. Look 8-10 feet ahead, but at nothing in particular.

7. Keep Your Eye Covered for 5 minutes.

Part 3: AFTER 5 MINUTES

Open your eyes. For the 2 symptoms that you identified at the beginning of this test, consider how you feel right now. Rate each symptom from 1-10, where 10 is the most severe and 1 is the least.

Dizziness (after test)

Selected Value: 1

Nausea (after test)

Selected Value: 1

Headache (after test)

Selected Value: 1

Neck Ache (after test)

Selected Value: 1

Anxiety (after test)

Selected Value: 1

Sensitivity to Light (after test)

Selected Value: 1