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Advantage Eyecare Low Vision Formadmin2017-07-06T01:14:26+00:00

Advantage Eyecare Low Vision Patient Welcome Form

  • MM slash DD slash YYYY
  • MM slash DD slash YYYY
  • Reported Diagnoses

    Please list all reported low vision diagnoses, and the eyes affected.
  • Ocular History

    Please list the date, doctor, treatment type, and eyes affected for any eye treatment, laser, or surgery.
  • MM slash DD slash YYYY
  • Additional Treatment/Surgery

    If you have had more than one treatment/surgery, please enter the same information in the numbered fields below.
  • MM slash DD slash YYYY
  • MM slash DD slash YYYY
  • Eye Medications and Vitimins

  • Name of medicationDosageTaken 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.
  • Diagnoses ConditionsMedications or VitaminsDate Diagnosed 
  • Diagnoses ConditionsMedications or VitaminsDate Diagnosed 
  • Diagnoses ConditionsMedications or VitaminsDate Diagnosed 
  • Diagnoses ConditionsMedications or VitaminsDate Diagnosed 
  • Diagnoses ConditionsMedications or VitaminsDate Diagnosed 
  • Diagnoses ConditionsMedications or VitaminsDate Diagnosed 
  • Diagnoses ConditionsMedications or VitaminsDate Diagnosed 
  • Living Situation

  • Task Analysis

  • A. Traveling

  • B. Distance Viewing

  • C. Daily living activities

  • D. Near Tasks

  • E. Lighting considerations

  • F. Job/School Related Tasks

    If not applicable, please skip section
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