AdaptiVision Low Vision Questionnaire
This form will help us understand your vision needs. It will take approximately 10 minutes to complete. Thank you for your time.
Email address *
First name
Your answer
Last name
Your answer
Phone number
Your answer
Are you completing this questionnaire for yourself, or for someone else?
If you are completing this form for someone else, please indicate the name of the person you are assisting and your relationship to him or her:
Your answer
Part I
Please answer the following questions regarding your vision while using glasses or contact lenses, as applicable.
Have you ever felt that vision problems make it difficult to do the things you would like to do?
Can you see regular print in newspapers, magazines, or books?
Can you see large print text such as large print headlines in the newspaper?
When you are crossing the street, can you see the "WALK" sign and street names?
Do vision problems interfere with your ability to watch TV or other hobbies such as sewing or playing cards?
Do you have difficulty seeing the labels on medicine bottles or reading prices when you shop?
Do you have difficulty writing due to vision problems?
Can you recognize the faces of family or friends when you enter a room?
Do you have difficulty finding the best lighting to optimize your vision in the home or office?
Do you tend to sit close to the television?
Do you have difficulty with glare, such as glare from a computer or television screen?
Optional: Have you received a vision diagnosis such as macular degeneration or retinitis pigmentosa (RP)? If so, please list your condition here:
Your answer
Optional: Please indicate the name(s) of your current optometrist and/or retina specialist:
Your answer
Are you interested in a free product demonstration at your home or office? Please select "yes" and one of our representatives will contact you to arrange an appointment.
Part II
To help us understand your needs, please consider the following questions regarding your interests and activities.
Please check all products that are of interest to you:
I would like advice on visual aids to assist me with the following activities (please check all that apply):
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