Vision Rehabilitation Needs Assessment

Because of your vision, do you have trouble reading regular size printed materials?
Yes
No

Because of your vision, do you have trouble signing your name on a document?
yes
no

Because of your vision, do you have trouble making a phone call without operator assistance?
yes
no

Because of your vision, do you have trouble telling time with a watch or clock?
yes
no

Because of your vision, do you have trouble managing your personal affairs?
yes
no

Do you have trouble recognizing people?
yes
no

Do you have trouble watching TV?
yes
no

Because of your vision, do you have trouble with activities of daily living (i.e. cooking, sewing, shopping or personal grooming)?
yes
no

If you drive, do problems with your sight cause you to be fearful when driving?
yes
no

Because of your vision, do you have trouble with independent travel at home or in the community?
yes
no

How do you feel about your life right now, on a scale of 1 to 10
(1 = worst, 10 = best)?

worst 1 2 3 4 5 6 7 8 9 10 best