- What have your doctors told you is the cause of your visual problems?
- Who was your doctor?
- When were you first diagnosed?
- When was your last eye exam and by whom?
- Have you ever had treatment or surgery for your eyes?
- If yes, when and which eye?
- Have you had recent changes in your vision?
- Do you wear glasses now?_______ If so, do they help?
- What bothers you the most about your vision?
- What are your main goals you want us to help you accomplish?
- Can you read newspaper print?
- Do you use magnifiers?
- Can you watch television?
- Do you still drive?
- Does sunlight bother your eyes?
- Do you wear sunglasses?
- 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
(Please circle Yes or No for each question.)
