Get Low Vision History Form - D3adjw0o5v66jd.cloudfront.net 2020-2025

Completing the Low Vision History Form is an essential step in understanding and managing your visual impairment. This guide provides detailed instructions to help you accurately fill out each section of the form online.

Follow the steps to complete the form smoothly.

1. Press the ‘Get Form’ button to obtain the form and open it in the online editor.
2. Enter your name in the designated fields: first name, middle initial, and last name. Also, note today's date.
3. Fill in your complete address, including street, city, state, and zip code.
4. Provide your home phone number and social security number in the respective fields.
5. Indicate your gender by checking the appropriate box (male or female) and provide your age and date of birth.
6. Record the date of your last eye examination and the name of the doctor who conducted it, along with the city and state.
7. Specify the diagnosis or name(s) of your eye condition or vision problem. Make sure to detail any additional notes.
8. Indicate when your vision loss began and rate your current vision using the options: great, good, fair, or poor.
9. Answer whether your vision has changed recently and out of which eye you feel you see better.
10. List any medical or surgical treatments you have received for your eyes. Also, specify any eye medications you are currently taking.
11. Record any other medications you are taking, providing details as needed.
12. Describe your general health status and any current health problems.
13. Indicate whether anyone in your family has the same eye condition.
14. Specify whether you currently wear glasses and provide details.
15. If applicable, indicate whether you use magnifiers or low vision devices, and list them.
16. Indicate if you have had a low vision exam before and your highest completed grade level.
17. Provide information about your current occupation and whether you are employed, retired, or unemployed.
18. State whether you primarily use vision or braille for reading.
19. Share your hobbies or interests.
20. Indicate if you are bothered by glare and whether you use a cane or guide dog.
21. In the provided section, check 'No' or 'Yes' for each vision-related task listed.
22. Answer what vision-related tasks you would like to be able to do, in the specified area.
23. Add any additional comments or concerns in the space provided.
24. Once you have filled out the form, you can save your changes, download, print, or share the form as needed.

Complete your forms online to ensure efficient processing and support for your low vision needs.