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LowVisionPatientQuestionnaire Today’sDate:____________________ PatientName:_______________________________________________________ DateofBirth:________________________________________________________ Whatareyourchiefcomplaintsaboutyourvision? ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ Isanyoneaccompanyingyoutoyourvisit?Yes No EmoryEyeCenterrespectsyourrighttoprivacy.Ifyouwouldliketogiveyour permissionformedicaland/oraccountinginformationtobediscussedwitha familymemberorfriend,pleaseprovidehis/hername: Name:_____________________________________________________________ Relationship:_________________________ Date:______________________ 1 MedicalHistory PastMedicalHistory Arthritis Asthma Cancer(pleasespecify) Diabetes HeartDisease Hypertension KidneyDisease SkinDisease Stroke NeurologicDisorder Yearof Diagnosis Yes No Details SURGERYORHOSPITALIZATION Surgery/ Hospitalization Year Details CURRENTMEDICATIONS Pleaseusebackofthispageifadditionalspaceisneeded Medication Nocurrentmedications AmountPerDay Reason 2 ALLERGIES Noknownallergies Allergies Reaction SOCIALHISTORY Smoke:Formersmoker NeversmokerYes;frequency? _________________ FAMILYHISTORY FamilyHistoryof Details Illness/Disease OcularDisease Diabetes HeartDisease Hypertension Other(pleaseexplain) Relationship OCULARHISTORY Disease/Illness Cataract Glaucoma MacularDegeneration Other(pleaseexplain) Diagnosedwhen (month/year)? Surgery/Treatment? 3 REVIEWOFSYSTEMS Pleaseindicateyesornoasdeemedappropriateregardingthefollowingsymptoms. NO YES Eyes Blurredvision Changeinvision Eyepain Comment ____________________________________ ____________________________________ ____________________________________ Constitutional/Symptoms Changeinweight Changeinactivitylevel Changeingeneralhealth ______________________________________ ______________________________________ ______________________________________ Ear,Nose,Throat&Mouth Hearingproblem Throatsoreness Nasaldrainage ______________________________________ ______________________________________ ______________________________________ Cardiovascular Chestpain Irregularheartbeat ______________________________________ ______________________________________ Respiratory Shortnessofbreath Wheezing ______________________________________ ______________________________________ Gastrointestinal(G.I.) Abdominalpain Diarrhea Constipation Vomiting ______________________________________ ______________________________________ ______________________________________ ______________________________________ Genitourinary (G.U.) Painordifficultywithurination____________________________________ Bloodordiscolorationinurine____________________________________ 4 NO YES Musculoskeletal JointPainorswelling Musclepainorweakness Comment ______________________________________ ______________________________________ Integumentary(Skin) Rash Itching ______________________________________ ______________________________________ Neurological Headache ______________________________________ Dizziness ______________________________________ Weaknessorgaitdisturbance______________________________________ Numbnessortingling ______________________________________ Psychiatric Anxiety Depression Emotionalchanges Inconsolable ______________________________________ ______________________________________ ______________________________________ ______________________________________ Endocrine Changeinsleeporeating ______________________________________ Coldorheatintolerance ______________________________________ Abnormalgrowth/development___________________________________ Hematologic/Lymphatic Frequentbruisingorbleeding______________________________________ Frequentinfections ______________________________________ Allergic/Immunologic Environmentalorfoodallergies____________________________________ AdditionalHistory 1. Doyouhaveanydifficultyhearing? 2. Doyouuseahearingaid? Yes No Yes No 5 3. DoyouuseAmericanSignLanguage? Yes No 4. Haveyoueverhadastroke? No Yes 5. Whattypesofproblemshaveyouhadasaresultofthestroke? ¨ Speechlimitations ¨ HearingProblems ¨ Weakness ¨ Decreasedsensation ¨ Decreasedcognition(memory,attention) ¨ Decreasedvision ¨ Partialparalysis ¨ Decreasedcoordination ¨ Decreasedbalance ¨ None DailyLiving 1. Whatbestdescribesyourpresentlivingarrangements? ¨ Livealone ¨ Withspouseorothercompanion ¨ Withadultchildren ¨ Withyoungchildren ¨ Withsiblings/parents/orotherguardian 2. Doyouliveina/an: ¨ House ¨ Apartment/Condo/Townhome ¨ NursingHome ¨ RetirementCommunity ¨ IndependentLivingCommunity ¨ Other_______________________________ 6 3. Whatsupportservicesprovideyouwithassistancenow? ¨ None ¨ Familymembers ¨ Friends ¨ Communitysponsoredservices ¨ Churchgroupsorserviceorganizations(i.e.Lion’sClub) ¨ School ¨ Vocationalrehabilitation/othergovernmentagency ¨ Homehealthcareservices ¨ Supportgroups ¨ Hospitalorotherprivateagencysponsoredservices 4. Doyouhaveanyofthefollowingresponsibilities?(checkallthatapply) ¨ Housekeeping ¨ Cooking ¨ Laundry ¨ Shopping ¨ Managingpersonalorfamilyfinances ¨ Careforspouseorotheradult ¨ Careforchildren ¨ Homerepairs/maintenance ¨ Other___________________________________ Atthepresenttime,Idonotmanageanyresponsibilities 5. Howdifficultisitforyoutoperformeverydayactivities?(example:managing finances,housekeeping,usingthetelephone,watchingTV) ¨ Notdifficult ¨ Verydifficult ¨ ¨ Mildlydifficult Moderatelydifficult ¨ Impossibletodo 6. Dootherphysicaldisabilitieslimityouinyourabilitytoperformeveryday activities? Yes No Ifyes,howmuchphysicaldisabilitieslimityourabilitytoperformdaily activities? 7 ¨ Moderatelydifficult ¨ Considerablydifficult ¨ Impossible 7. Haveyouhadrehabilitation/outpatient/homehealthinthepast? Yes No Ifyes,pleasedescribe____________________________________________ Education/Work 1. Levelofformaleducation: ¨ None ¨ Grade6orless ¨ Somehighschool ¨ Highschoolgraduate ¨ Somecollegeortechnicalschool ¨ Collegeortechnicalschoolgraduate ¨ Somepostgraduatestudy ¨ Professionaloradvancedgraduatedegree 2. Areyourretired? Yes No 3. Areyoureceivingdisability? Yes No 4. Areyoucurrentlyemployed? Yes No FullTime PartTime Ifyes,whatisyouroccupation?__________________________ 5. Hasyouremployermadeaccommodationforyouvisualimpairment?(i.e. largecomputerscreen) Yes,fulltime No Notapplicable 6. Areyouseekingemployment? Yes No 8 Driving 1. Areyoulicensedtodrive? Yes No 2. Doyoucurrentlydrive? Yes No Ifyoudonotdrive,whendidyoulastdrive?___________________ 3. Ifyoudodrive,doyoulimityourdrivinginanyway?Yes No Ifso,how? ¨ DaytimeOnly ¨ Ruralroadsonly ¨ Familiarareasonly ¨ Geographic/certainroutes ¨ Lowtrafficroads ¨ Nohighways/interstates ¨ Notinbrightsunlight ¨ Notinbadweather 4. Doyoudriveatnight? Yes No 5. Anycrashesornearmissesoverthelast2years?Yes No 6. Howwouldyouratethequalityofyourdriving? ¨ Excellent ¨ VeryGood ¨ Good ¨ Fair ¨ Poor 7. Whatareyourcurrentsourcesoftransportation?(checkallthatapply) ¨ Driveself ¨ Family/Friends ¨ PublicTransportation ¨ Taxi/Uber/otherchaufferservice ¨ Specialtransportation ¨ Other_________________________________ 8. Canyouwalktopublictransportationfromyourhome?Yes No Ifso,doyou? Yes 1 No 9 Vision 1. Haveyoueverhadalowvisionexam?Yes No Ifso,when:______________________ 2. Atwhatagedidyoudevelopsignificantproblemswithyourvision? ¨ Birthto5years ¨ 41to60years ¨ 6to18years ¨ Olderthan60years ¨ 19to40years 3. Doyouhavedifficultyreading? Yes No 4. Ifapplicable,whendidyoustarthavingproblemsreading? ¨ Lessthan6monthsago ¨ 6to12monthsago ¨ 1to2yearsago ¨ Morethan2yearsago 5. Whattypeofmaterialsdoyouhavedifficultyreading?(checkallthatapply) ¨ Newspapers ¨ Largeprintbooks ¨ Mail/Bills ¨ Medicinebottles ¨ PriceTags ¨ Packagedirections ¨ Standard-printbooks 6. Doyouusemagnifierstoassistyourreading? Yes No 7. Dolightingconditionsimprovehowwellyoucandoeverydayactivities? ¨ MajorEffect ¨ Moderate ¨ Noeffect 8. Doesyourvisiongiveyoudifficultywithrecognizingpeople? ¨ Notdifficult ¨ ModeratelyDifficult ¨ VeryDifficult ¨ Impossible 10 9. Doyouhaveanydifficultiesseeingthetelevision?Yes Whatsizeisthescreen? ________inches Howfarawayifthescreen? ________feet No 10. Doesyourvisiongiveyoudifficultygettingaroundbyyourself? ¨ Notdifficult ¨ ModeratelyDifficult ¨ VeryDifficult ¨ Impossible 11. Becauseofyourvision,howdifficultisitforyoutotakecareofyourmedical concerns? ¨ Notdifficult ¨ ModeratelyDifficult ¨ VeryDifficult ¨ Impossible 12. Becauseofyourvision,howdifficultisitforyoutotakecareofyourpersonal hygiene? ¨ Notdifficult ¨ ModeratelyDifficult ¨ VeryDifficult ¨ Impossible 13. Canyouperformbasicself-care(grooming,bathing,dressing)? Yes No 14. Canyoumanageyourfinances(filloutforms,paybills,etc.)? Yes No 15. Canyouperformbasichomemanagement(fixinglunch,cleaning)? Yes No 16. Overthepastyear,doyoufeelthatyourvisionhas? ¨ Gottenworse ¨ Remainedthesame ¨ Improved ¨ 11 17. Doesyourvisionfluctuate? Yes No 18. Whatvision-relatedrehabilitationserviceshaveyouhad?(checkallthat apply) ¨ None ¨ Trainingintheuseoflowvisiondevices ¨ Orientationandmobilitytraining ¨ Everydaylivingskills(personalhygiene,homemanagement) ¨ Vocationalrehabilitation ¨ Psychologicalrehabilitation ¨ Eccentricviewtraining ¨ Socialwork ¨ Blindnessskillstraining ¨ Other:_____________________________________________________ 19. Haveyouparticipatedinasupportgroupforvisionproblems? Yes No 20. Areyoureceivingpsychologicalcounselingbyatherapist? Yes No 21. Whatisthebestdescriptionofyourmemory? ¨ Noproblems ¨ Occasionalperiodofforgetfulness ¨ Frequentlyforgetful ¨ Confused 22. Howwouldyoudescribeyourcurrentemotionalstate? ¨ ¨ ¨ ¨ Welladjusted Depressed Difficultycoping Anxious ¨ ¨ ¨ ¨ Angry Frightened Frustrated Sad 12 23. Whattypesoflowvisiondevicesdoyouusenoworhaveyoutriedinthe past?(checkallthatapply) Device UseNow Triedinthe Past None Hand-HeldMagnifier StandMagnifier Prismhalf-eyes Highpowerbifocals Hyperoculars/verystrongglasses Loupes Hand-Heldtelescope Head-worntelescope/binoculars Telescopemountedinglasses CCTVorvideomagnifier Highintensitylamps Darkglasses Glasseswithcolortint Talkingbooks/readingservices Speechoutputreadingmachine Largeprintcomputersystem Largeprintbooks,magazines,etc. Whitesupportcane Whitelongcane Othermobilityaid GuideDog(seeingeye) Other:________________________ 13 PhysicalState 1. Doanyofthefollowingmobilitylimitationsapplytoyou?(checkallthat apply) None ¨ Usesupportcane ¨ Usebattery-operatedscooter ¨ Usecrutches ¨ Requireassistancewalking ¨ Usewalker ¨ Usesupportrail ¨ Usewheelchair ¨ bedridden 2. Doyouhaveanyhandproblems?(checkallthatapply) ¨ None ¨ Canonlyuseonehand ¨ Handshakes ¨ Numbness/tingling ¨ Missingfingers ¨ Difficulthandlingsmallobjects 3. Doyouhavemotionlimitations?(checkallthatapply) ¨ ¨ ¨ None ¨ Headshakes ¨ Limitedhead/neckmovement Limitedarmmovement Limitedbalancewhenseated Thankyoufortakingtimetocompletethisform.Itwillbe helpfultousinprovidingyouwiththebestcarepossible. - YourVisionRehabilitationTeam - 14
