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Advantage Eyecare Low Vision Form
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2017-07-06T01:14:26+00:00
Advantage Eyecare Low Vision Patient Welcome Form
Today's Date
MM slash DD slash YYYY
Name
First
Last
Date of Birth
MM slash DD slash YYYY
Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Phone Number
Referred By:
Do you wish for us to send a report to your eye doctor?
Yes
No
Name of your Eye Doctor
Have you had previous low vision care?
Yes
No
If 'Yes' when and where?
Have you had previous low vision devices?
Yes
No
If 'Yes" From whom if different from above?
Reported Diagnoses
Please list all reported low vision diagnoses, and the eyes affected.
1. Diagnoses
1. Which Eye(s)?
Left
Right
Both
2. Diagnoses
2. Which Eye(s)?
Left
Right
Both
3. Diagnoses
3. Which Eye(s)?
Left
Right
Both
4. Diagnoses
4. Which Eye(s)?
Left
Right
Both
Ocular History
Please list the date, doctor, treatment type, and eyes affected for any eye treatment, laser, or surgery.
1. Date of Treatment/Surgery
MM slash DD slash YYYY
1. Doctor
1. Type of Surgery/Treatment
1. Which Eye(s)?
Left
Right
Both
Additional Treatment/Surgery
If you have had more than one treatment/surgery, please enter the same information in the numbered fields below.
2. Date of Treatment/Surgery
MM slash DD slash YYYY
2. Doctor
2. Type of Treatment/Surgery
2. Which Eye(s)?
Left
Right
Both
3. Date of Treatment/Surgery
MM slash DD slash YYYY
3. Doctor
3. Type of Treatment/Surgery
3. Which Eye(s)?
Left
Right
Both
Eye Medications and Vitimins
List your current medications
Name of medication
Dosage
Taken how often?
Reason prescribed
If you take more than one medication, please use the plus symbol to the right of the field to enter more.
General Health History
Please list medications and vitamins next to diagnosis conditions.
Diabetes
Diagnoses Conditions
Medications or Vitamins
Date Diagnosed
Hypertension (High Blood Pressure)
Diagnoses Conditions
Medications or Vitamins
Date Diagnosed
Heart Disease
Diagnoses Conditions
Medications or Vitamins
Date Diagnosed
Arthritis
Diagnoses Conditions
Medications or Vitamins
Date Diagnosed
Parkinson's
Diagnoses Conditions
Medications or Vitamins
Date Diagnosed
Thyroid
Diagnoses Conditions
Medications or Vitamins
Date Diagnosed
Allergies
Diagnoses Conditions
Medications or Vitamins
Date Diagnosed
Hearing Loss?
Yes
No
If 'Yes' please specify
Hearing Aid?
Yes
No
Other Conditions and Medications:
Living Situation
With whom does the patient live?
Employment Status
Retired
On Leave
Homemaker
Employed Full-time
Employed Part-time
Unemployed/ Not seeking Employment
Unemployed/ Seeking Employment
Reason for status or job description
Is your job in jeopardy?
Yes
No
N/A
Have you considered retiring/resigning because of vision?
Yes
No
N/A
Social Activities (Church, Senior Center, ect)
Other Limitations (difficulty walkings, tremors, ect)
Who will accompany patient to the exam?
Relationship
Phone Number
Alternative Phone Number
Task Analysis
A. Traveling
Do you travel alone?
Yes
No
Do you have difficulty travelling locally alone?
Not a problem
Mild problem
Major Problem
Patient Objective
Do you have difficulty travelling far?
Not a problem
Mild problem
Major Problem
Patient Objective
Do you have difficulty seeing to drive a car?
Not a problem
Mild problem
Major Problem
Patient Objective
Do you have difficulty seeing traffic lights?
Not a problem
Mild problem
Major Problem
Patient Objective
Do you have difficulty seeing street signs?
Not a problem
Mild problem
Major Problem
Patient Objective
Do you have difficulty crossing streets?
Not a problem
Mild problem
Major Problem
Patient Objective
B. Distance Viewing
Do you have difficulty crossing streets?
Not a problem
Mild problem
Major Problem
Patient Objective
Do you have difficulty seeing curbs and stairs?
Not a problem
Mild problem
Major Problem
Patient Objective
Do you have difficulty walking without falling?
Not a problem
Mild problem
Major Problem
Patient Objective
Do you have difficulty seeing faces?
Not a problem
Mild problem
Major Problem
Patient Objective
Do you have difficulty seeing at the theater?
Not a problem
Mild problem
Major Problem
Patient Objective
Do you have difficulty seeing the TV?
Not a problem
Mild problem
Major Problem
Patient Objective
At what distance do you have trouble seeing the TV?
C. Daily living activities
Do you have difficulty doing your housework?
N/A
Not a problem
Mild problem
Major Problem
Patient Objective
Do you have difficulty seeing to cook?
N/A
Not a problem
Mild problem
Major Problem
Patient Objective
Do you have difficulty seeing stove dials?
N/A
Not a problem
Mild problem
Major Problem
Patient Objective
Do you have difficulty seeing flame on stove?
N/A
Not a problem
Mild problem
Major Problem
Patient Objective
Do you have difficulty seeing food on your plate?
N/A
Not a problem
Mild problem
Major Problem
Patient Objective
Do you have difficulty seeing a phone/using a phone?
N/A
Not a problem
Mild problem
Major Problem
Patient Objective
Do you have difficulty seeing to groom yourself?
N/A
Not a problem
Mild problem
Major Problem
Patient Objective
D. Near Tasks
Do you have difficulty reading headlines?
N/A
Not a problem
Mild problem
Major Problem
Patient Objective
Do you have difficulty reading regular print books?
N/A
Not a problem
Mild problem
Major Problem
Patient Objective
Do you have difficulty reading phonebooks/small print?
N/A
Not a problem
Mild problem
Major Problem
Patient Objective
Do you have difficulty seeing prices/labels?
N/A
Not a problem
Mild problem
Major Problem
Patient Objective
Do you have difficulty reading your mail/bills?
N/A
Not a problem
Mild problem
Major Problem
Patient Objective
Do you have difficulty reading handwritten material?
N/A
Not a problem
Mild problem
Major Problem
Patient Objective
Do you have difficulty writing/signing name (checks, ect)?
N/A
Not a problem
Mild problem
Major Problem
Patient Objective
Do you have difficulty seeing color?
N/A
Not a problem
Mild problem
Major Problem
Patient Objective
Do you have difficulty filling a syringe (diabetics)?
N/A
Not a problem
Mild problem
Major Problem
Patient Objective
Do you have difficulty filling a syringe (diabetics)?
N/A
Not a problem
Mild problem
Major Problem
Patient Objective
Do you have difficulty seeing your medicine labels?
N/A
Not a problem
Mild problem
Major Problem
Patient Objective
Do you have difficulty seeing to sew/knit/crochet?
N/A
Not a problem
Mild problem
Major Problem
Patient Objective
Do you have difficulty seeing playing cards?
N/A
Not a problem
Mild problem
Major Problem
Patient Objective
Other difficulties
E. Lighting considerations
Do you have difficulty tolerating the sun well?
N/A
Not a problem
Mild problem
Major Problem
Patient Objective
Do you have difficulty seeing on cloudy/rainy days?
N/A
Not a problem
Mild problem
Major Problem
Patient Objective
Do you have difficulty seeing in dim light?
N/A
Not a problem
Mild problem
Major Problem
Patient Objective
Do you have difficulty going from bright to dim light?
N/A
Not a problem
Mild problem
Major Problem
Patient Objective
Do you wear sunglasses?
Yes
No
Are your sunglasses effective?
Yes
No
Does bright light help you?
N/A
No
Yes, alittle bit
Yes, a lot
Preferred light source
Incandescent
Fluorescent
Hi-Intensity
F. Job/School Related Tasks
If not applicable, please skip section
Do you have difficulty using a computer?
N/A
Not a problem
Mild problem
Major Problem
Patient Objective
Do you have difficulty using tools and equipment?
N/A
Not a problem
Mild problem
Major Problem
Patient Objective
Do you have difficulty reading instruments/indicators?
N/A
Not a problem
Mild problem
Major Problem
Patient Objective
Do you have difficulty moving within worksite/school?
N/A
Not a problem
Mild problem
Major Problem
Patient Objective
Do you have difficulty seeing the blackboard in class?
N/A
Not a problem
Mild problem
Major Problem
Patient Objective
Task analysis completed by:
Signature
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