VISION REHABILITATION QUESTIONNAIRE · VISION REHABILITATION QUESTIONNAIRE Patient Name Date As low vision optometrists, we want enough information so that we can, as closely as possible,

www.LowVisionCare.ca

VISION REHABILITATION QUESTIONNAIRE

Patient Name Date

As low vision optometrists, we want enough information so that

we can, as closely as possible, understand and visualize what you

see. We would greatly appreciate if you would fill out this

questionnaire as completely as possible and bring it with you

when you come in for your appointment. You may also email it to

the clinic.

Who referred you to the Low Vision clinic?

Please check the following eye conditions that apply to you;

Retinitis Pigmentosa (RP)

Albinism

Retinopathy of Prematurity

Macular Hole

Macular Degeneration(ARMD)

Glaucoma

Cataracts

Diabetic Eye Disease

Other: Please specify

When were you initially diagnosed?

www.LowVisionCare.ca B

Who is your primary eye care Optometrist, if any?

Name the Ophthalmologist(s) that you see:

When was your last eye exam with your:

Optometrist: frequency

Ophthalmologist frequency

GENERAL MEDICAL HISTORY

Diabetes

Hypertension

Heart disease

High Cholesterol

Please check all the following systemic conditions that apply to

you: History of a stroke

Arthritis

Cancer

Neurological condition

Other

2


Please list all medications you are currently taking;

Do you have any difficulty hearing?

Yes

No

PHYSICAL STATE

Do you have other limitations such as difficulty walking, tremors,

hand or arm weakness?

Yes - Describe:

No

Use a walker

Use a wheelchair

Do you use a hearing aid?

Yes

No

3


What best describes your current living arrangement?

With sibling or other relative

With parents or guardian

Have a full time aide

Have a part-time aide

Live alone

With a spouse or other companion

With adult children

With young children

Do you live in a/ an:

house

apartment

condominium

townhouse

nursing home

independent living facility /

retirement community

other

What are your current sources of transportation?

Other – describe

Drive self

Ride with family or friends

Public transportation

Chauffeur service

Taxi cabs

Special transportation service

4


Will anyone be accompanying you to your visit

No

Yes who?

What is or was your occupation?

VISION

To the best of your ability, please describe your vision.

Have you had any changes in vision since your last eye exam?

Yes

No

Over the last year, do you feel your vision:

Has gotten worse

Has remained the same

Has improved

5


Which do you feel is your better eye?

Right

Left

Please list any ocular treatments / surgeries you have had, the

date they were performed, and the doctor who performed the

procedure:

Please list any eye medications or vitamins you are currently

taking:

Have you had any previous low vision care?

Yes

No

Have you had Orientation & Mobility training?

Yes

No

6


If “Yes”, how long ago?

With Whom?

Please list all devices that you are currently using, or have

used in the past, to improve your vision:

Are you registered with the CNIB?

Yes

No

I don’t know what this is

Have you ever accessed the Assistive Devices Program (ADP)?

Yes

No

I don’t know what this is

If “Yes”, how long ago? for what?

7


Check if you have difficulty:

Seeing curbs and steps

Walking without tripping

Seeing faces

Seeing TV. How far do you sit from the TV?

Seeing at the theatre

Seeing traffic lights/street signs

Check if you have difficulty performing any of the following

daily living activities:

Doing your housework

Seeing to cook

Seeing the food on your plate

Seeing/using the phone

Seeing to groom yourself (eg. Cutting finger nails)

1. DISTANCE TASKS

8


2. NEAR TASKS

How long since you have read without any magnifier or help?

Check if you have difficulty:

Reading headlines

Reading regular print books

Reading newsprint/small print

Seeing prices or labels

Reading your mail or bills

Writing/signing your name

Seeing to sew/knit /crochet

Seeing playing cards

Seeing your medication labels

3. LIGHTING CONSIDERATIONS

Check if you have problems:

Tolerating the sun

Glare Problems Indoors

Glare from Computer

On cloudy/rainy days

Going from bright to dim light

Seeing in dim light

Do you wear sunglasses?

Yes

No

9


If you wear sunglasses, are they effective?

Yes

No

Does bright light help you perform tasks?

Yes

No

What social activities do you have? Please list

VISUAL GOALS

Please list activities that you are no longer able to do because

of your vision that you would like to be able to do again. Please

be as specific as possible (i.e. Instead of “reading”, tell us

exactly what you would like to read.)

1.

2.

3.

10


4.

5.

If you had to choose one activity on the above list that you

would consider “top priority”, which would you choose?

Are there any other issues about yourself or your vision that

you feel the doctor should be aware of?

How would you describe your current emotional state:

Difficulty coping

Frustrated

Anxious

Sad

Well-adjusted

Depressed

Angry

Frightened

11

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VISION REHABILITATION QUESTIONNAIRE · VISION REHABILITATION QUESTIONNAIRE Patient Name Date As low vision optometrists, we want enough information so that we can, as closely as possible,