Eccentric Viewing Training Assessment Form
Assess eccentric viewing training status, viewing habits, and everyday functional performance using a modern, minimal form layout.
Participant Background
First Name
*
Age Range
*
Under 18
18–29
30–44
45–59
60–74
75+
Primary Eye Condition or Reason for Assessment
*
Macular degeneration
Central vision loss
Low vision training follow-up
Other
Current Vision and Training Status
Preferred Viewing Eye
*
Right
Left
Either/No Preference
Other
Currently Uses Eccentric Viewing Techniques
*
Yes
No
Not sure
Experience With Eccentric Viewing Training (Years or Months)
Assessment of Viewing Habits
Rate how often you use peripheral retinal areas for each task
*
Rows
Never
Rarely
Sometimes
Often
Always
Reading using peripheral vision
1
2
3
4
5
Recognizing faces using peripheral vision
6
7
8
9
10
Locating objects using peripheral vision
11
12
13
14
15
Maintaining fixation away from the central blind spot
16
17
18
19
20
How confident are you in using eccentric viewing during daily tasks?
*
Not at all confident
1
2
3
4
5
6
7
8
9
Extremely confident
10
1 is Not at all confident, 10 is Extremely confident
Functional Reading and Daily Task Performance
Task performance and strategy use
*
Rows
Difficulty level
Uses eccentric viewing strategies
Reading print
21
22
Using a phone
23
24
Navigating indoors
25
26
Identifying distant signs
27
28
Finding items on a table
29
30
Main task to improve most
Submit Assessment
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