VISION QUESTIONNAIRE

VISION QUESTIONNAIRE
The answers to these questions will help us determine whether your condition is disabling within the meaning of the law. Please fully explain your answers wherever possible by giving descriptions and examples.
CLAIMANT NAME:
SSN:
Email:
You will receive confirmation email at this address.
1) What are your chief complaints about your vision?

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2) Which eye is involved?
3) Where and when was your most recent eye exam?
a) Date of exam:

MonthDayYear
b) Name of Provider:
c) Address:
d) Phone:
Format: (000) 000-0000.
e) What visual diagnosis did your doctor give you?

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4) Tell us about any upcoming vision exams or eye surgeries you have scheduled.

0/525
5) Do you wear glasses or contact lenses?
a) Are you able to drive a car while wearing corrective lenses?
If yes, do you have any specific restrictions on your driver’s license?

0/100
b) Do you have any difficulties navigating your home or any other setting while wearing corrective lenses?
If yes, please provide details:

0/225
c) Are you able to read print such as mail, newspaper, cell phone, or computer screens while wearing your corrective lenses?
If no, please describe how you deal with those issues:

0/225
d) Have you changed or stopped certain activities due to your visual condition?
If yes, please provide details:

0/225
6) Do you have any deficits in your peripheral vision for one or both eyes?
If yes, please provide details:

0/225
7) Do you use a guide dog, white cane, magnifiers, Video Magnifier (CCTV) or other vision aids other than glasses or contacts? If so, then which aid(s) do you use and who prescribed it?

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Name of person completing this form:
(Please print)
Date:

MonthDayYear
Date
Telephone No.:
Please enter a valid phone number.Format: (000) 000-0000.
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Should be Empty: