Color Vision Screening Form
Please complete this form to help us understand your color vision ability. All questions are for general screening purposes only.
Full Name
*
First Name
Last Name
Age
*
Gender
*
Male
Female
Other / Prefer not to say
Do you have any known vision conditions (excluding color vision)?
*
No known conditions
Yes, nearsightedness (myopia)
Yes, farsightedness (hyperopia)
Yes, astigmatism
Other
Have you ever been told you have difficulty seeing certain colors?
*
No
Yes, red-green colors
Yes, blue-yellow colors
Yes, other color combinations
Do you have difficulty distinguishing colors in daily life (e.g., traffic lights, clothing, charts)?
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No, never
Occasionally
Frequently
Always
Are any family members known to have color vision difficulties?
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No
Yes, parent
Yes, sibling
Yes, other relative
Not sure
Have you ever taken a color vision screening before?
*
No
Yes, at school
Yes, at work
Yes, at a clinic/doctor's office
Yes, online
If you have taken a color vision screening, were any difficulties found?
*
No difficulties found
Yes, mild color vision deficiency
Yes, moderate color vision deficiency
Yes, severe color vision deficiency
Not applicable / Never screened
Please describe any challenges you experience with colors (if any):
Submit
Should be Empty: