Vision Form for Disability Evaluation

Vision Form for Disability Evaluation

(Click here for PDF version)

Name of Claimant:

SSN:

Diagnosis:

Right eye

Left eye

Pseudophakia: Right eye: YES______ NO______

Left eye: YES______ NO______

Visual Acuity: Distance NEAR DISTANCE NEAR

(Without correction) (With correction)

Right eye: ______ ______ ______ ______

Left eye: ______ ______ ______ ______

Is there any abnormality or limitation of field of vision?

YES______ NO______

Of yes, what is the widest diameter in degrees in remaining fields? (Please include copies of field tests)

Right eye:______ Left eye:______

Will visual function by impaired by prolonged or occasional:

Detailed vision: YES______ NO______

Lifting: YES______ NO______

Irritants: YES______ NO______

Is the patient able to see clearly enough for the following activities?

Driving a motor vehicle? YES______ NO______

Operating machinery? YES______ NO______

Reading small print? YES______ NO______

Reading large print? YES______ NO______

Eye-hand coordination tasks? YES______ NO______

Identifying details at close range? YES______ NO______

Working with a computer? YES______ NO______

Avoid the ordinary hazards in the workplace, such as boxes on the floor, doors ajar, or approaching people or vehicles? YES______ NO______

Does the patient have any complaints of any of the following?

______ Blurred vision

______ Loss of vision

______ Obstruction of vision

______ Eye pain

______ Other

Additional comments:

Physician’s signature: Date:

Print name: