NAME________________________________ DATE___________________
VISION PROBLEMS AND CONCERNS
LIMITATIONS
Does your vision at times make it a problem for you to:	YES	NO
Read a newspaper	_____	_____
Read a telephone book	_____	_____
See traffic signs	_____	_____
Recognize people	_____	_____
See steps or curbs well	_____	_____
Watch TV	_____	_____
Work at your job	_____	_____
Manage your home	_____	_____
Enjoy recreation and leisure	_____	_____
Blurry vision in one eye interferes with better vision in other eye	_____	_____

SYMPTOMS
Have you been bothered at times by:	YES	NO
Poor night vision	_____	_____
Seeing rings around lights	_____	_____
Glare	_____	_____
Blurry vision	_____	_____
Seeing in poor or dim light	_____	_____
	_____	_____

DRIVING
Does your vision sometimes make it difficult to drive:	YES	NO
During daylight hours	_____	_____
During evening/night hours	_____	_____

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