FUNCTIONAL VISION QUESTIONNAIRE
To help us serve you better, please fill out the questionaire and bring it with you when you come in for your appointment.
Do you have assistance with your daily needs?
If yes, then who?
NEARWORK: (CHECK OFF YOUR GOALS)
Crafts or Mechanical Work
Bills and Mail
Large Print Books
Shaving ot Makeup
DISTANCE WORK:(CHECK OFF YOUR GOALS)
Driving or Transportation
Airport or Grocery isle Signs
Far Away Menus
Steps and Curbs
GLARE OR WHEN LIGHT BOTHERS YOU:
Changing Light to Dark or Reverse
Issues Not Addressed
San Antonio Low Vision Clinic 9577 Huebner Rd. Bldg. 4 San Antonio, Texas 78240 210-228-0030