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Wisconsin Department of Health Services

 

Functional Vision Screening Questionnaire

PDF Version of Functional Vision Screening Questionnaire (PDF, 9 KB)

This is a screening to identify older people with a vision problem. People who use glasses or contact lenses should answer the questions in terms of how they see when wearing their glasses or contact lenses. This does not include the use of low vision devices or magnifiers. Read the questions aloud if literacy is a concern:
  1. Do you ever feel that problems with your vision make it difficult for you to do the things you would like to do?
                                                                                   1. Yes         0. No
  2. Can you see the large print headlines in the newspaper?
                                                                                    0. Yes          1. No
  3. Can you see the regular print in newspapers, magazines or books?
                                                                                    0. Yes          1. No
  4. Can you see the numbers and names in the telephone book?
                                                                                    0. Yes          1. No
  5. When you are walking in the street, can you see the "WALK" sign and street names?
                                                                                    0. Yes         1. No
  6. When crossing the street, do cars seem to appear very suddenly?
                                                                                    1. Yes         0. No
  7. Does trouble with your vision make it difficult for you to watch TV, play cards, do sewing, or any similar type of activity?
                                                                                     1. Yes         0. No
  8. Does trouble with your vision make it difficult for you to see labels on medicine bottles?
                                                                                      1. Yes        0. No
  9. Does trouble with your vision make it difficult for you to read prices when you shop?
                                                                                       1. Yes       0. No
  10. Does trouble with your vision make it difficult for you to read your own mail?
                                                                                       1. Yes       0. No
  11. Does trouble with your vision make it difficult for you to read your own handwriting?
                                                                                       1. Yes      0. No
  12. Can you recognize the faces of family or friends when you are across an average size room?
                                                                                       0. Yes      1. No
  13. Do you have any particular difficulty seeing in dim light?
                                                                                       1. Yes      0. No
  14. Do you tend to sit very close to the television?
                                                                                       1. Yes      0. No
  15. Has a doctor ever told you that nothing more can be done for your vision?
                                                                                      1. Yes      0. No

Scores are indicated next to the answer for each item. A total score of nine (9) or more indicates the need for a vision examination conducted by a low vision optometrist or ophthalmologist.

                                                                               TOTAL ___________

 

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Last Revised: October 24, 2008