Low Vision Questionnaire
  1. What have your doctors told you is the cause of your visual problems?
  2. Who was your doctor?
  3. When were you first diagnosed?
  4. When was your last eye exam and by whom?
  5. Have you ever had treatment or surgery for your eyes?
  6. If yes, when and which eye?
  7. Have you had recent changes in your vision?
  8. Do you wear glasses now?_______ If so, do they help?
  9. What bothers you the most about your vision?
  10. What are your main goals you want us to help you accomplish?

  11. (Please circle Yes or No for each question.)
  12. Can you read newspaper print?
  13. Do you use magnifiers?
  14. Can you watch television?
  15. Do you still drive?
  16. Does sunlight bother your eyes?
  17. Do you wear sunglasses?
  18. Check any of the following activities that your vision causes you to have problems with.
    • Reading
    • Household
    • Books
    • Shopping
    • Magazines
    • Dials
    • Newspapers
    • Clocks
    • Large Print
    • Watches
    • Music
    • Eating
    • Other
    • Cooking
    • Sewing
    • Writing
    • Laundry
    • Letters
    • Cleaning
    • Checks
    • Signing