Vision Form for Disability Evaluation
Name of Claimant:
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?
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
Physician’s signature: Date:
Copyright 2018, Michael Reynard, M.D.