Vision Form for Disability Evaluation

posted in: Vision Impairment

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:

 

 

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