Low Vision Patient Assessment

Low Vision Patient Assessment
Please complete this assessment to help us understand your visual needs and challenges. This information will guide your care and support.
Patient Full Name
First NameLast Name
Date of Birth
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Contact Information (Email)
example@example.com
Contact Information (Phone)
Please enter a valid phone number.Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
CityState / ProvincePostal / Zip Code
Primary Reason for Assessment
Other
Medical and Vision History
Rows Yes No
Do you have a diagnosed eye condition?
Have you had eye surgery?
Do you use any low vision aids?
Do you have any other health conditions impacting your vision?

How would you rate the following visual difficulties?

Rows	No Difficulty	Mild	Moderate	Severe	Unable to Perform
Reading print (books, newspapers, labels)
Recognizing faces
Watching television
Mobility indoors (moving around your home)
Mobility outdoors (crossing streets, using public transport)

Overall, how would you rate your current vision?

1
2
3
4
5
1 is Very Poor, 5 is Excellent
Which of the following daily activities do you find most challenging due to your vision? (Select all that apply)
Other
Please describe any other visual challenges or goals you have for this assessment.
Should be Empty:

Select theme:

Rows	Yes	No
Do you have a diagnosed eye condition?
Have you had eye surgery?
Do you use any low vision aids?
Do you have any other health conditions impacting your vision?