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LOW VISION SCREENING INFORMATION
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Location of clinic
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Client address
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Phone
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Screener
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Referral Source
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Ophthalmologist/Optometrist
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Send Reports To - 1
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Send Reports To - 2
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Send Reports To - 3
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For SM clients only - vision appeal form taken?
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Name of School (School Children Only)
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Grade
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Teacher Consultant/Orientation and Mobility Specialist
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Do you use a computer?
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If yes, Windows, Apple, or Chromebook
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Ipad, Android Tablet or neither
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Smart Phone
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Type of phone
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LIVING ARRANGEMENTS
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Change in living arrangements
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Type of dwelling
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Do you presently drive
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Driving comments
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Are you having difficulty with daily living activities? If so, who do you get help from?
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PROBLEM IDENTIFICATION
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What has your doctor told you about your vision loss?
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COPING PATTERNS
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What difficulties are you experiencing and what are your goals regarding your vision?
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Other low vision goals
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Have you felt down/depressed/hopeless?
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Any changes in eating/sleeping?
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Noticed lessened interest/pleasure in activities?
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Are there any unexplained bruises or injuries, or the explanation is inconsistent with the injury?
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If normally dependent on someone else for care, is the client unkepmt, dirty, or have poor hygiene?
• • •
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Does the client exhibit excessive fear, loss of interest in self, or resignation?
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AMSLER GRID
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Amsler Grid OS
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Amsler Grid OD
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