Self Assessment Form

Full Name*

Email*

1. How Old Are You?*

2. Number of Years of Visual Impairment*

3. Has Your Vision Worsened In The Last Year?*

4. What is the cause of your reduced vision?*

5. What is the visual acuity of your right eye (with eyeglasses or contacts if they help)*

Do you wear glasses or contacts to achieve this visual acuity?

6. What is the visual acuity of your left eye (with eyeglasses or contacts if they help)*

Do you wear glasses or contacts to achieve this visual acuity?

7. Which is your dominant eye? It may NOT be your better-seeing eye.*

8. What is the furthest distance that you can recognize a family member's face by their features? (with both eyes open)*

9. Describe your vision - is it:*

10. When looking through a pair of binoculars, can you see much better at a distance?*

11. What vision goals are you hoping to improve - Seeing At Distance

What other distance vision goals would you hope to improve?

12. What vision goals are you hoping to improve - Seeing At Mid Range

What other mid range vision goals would you hope to improve?

13. What vision goals are you hoping to improve - Seeing At Short Range

What other short range vision goals would you hope to improve?

14. Anything you'd like to tell us.

15. Do you need a referral to a low vision specialist?

Your Address

City State / Province / Region ZIP / Postal Code Country

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