owlradio.org
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?
Yes
No
If yes, then who?
ARE YOU:
Retired
Disabled
Working
Student
Veteran
NEARWORK: (CHECK OFF YOUR GOALS)
Medicine Labels
Newspaper
Religous Books
Price Tags
Cooking
Crafts or Mechanical Work
Menus
Gardening
Bills and Mail
Check Writing
Large Print Books
Sewing
Games
Woodworking
Computer
Shaving ot Makeup
DISTANCE WORK:(CHECK OFF YOUR GOALS)
Television
Driving or Transportation
Crosswalks
Airport or Grocery isle Signs
Street Signs
Far Away Menus
Boardwork
Steps and Curbs
GLARE OR WHEN LIGHT BOTHERS YOU:
Outdoors
Changing Light to Dark or Reverse
Store Lighting
Issues Not Addressed
Santa Rosa Low Vision Clinic 315 N San Saba St. Suite 900 San Antonio, Texas 78207 210-228-0300
