AdaptiVision Low Vision Questionnaire

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This form will help us understand your vision needs. It will take approximately 10 minutes to complete. Thank you for your time.

Email *

First name

Last name

Phone number

Are you completing this questionnaire for yourself, or for someone else?

Myself

Someone else

Clear selection

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:

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?

Yes

Maybe

Clear selection

Can you see regular print in newspapers, magazines, or books?

Yes

Maybe

Clear selection

Can you see large print text such as large print headlines in the newspaper?

Yes

Maybe

Clear selection

When you are crossing the street, can you see the "WALK" sign and street names?

Yes

Maybe

Clear selection

Do vision problems interfere with your ability to watch TV or other hobbies such as sewing or playing cards?

Yes

Maybe

Clear selection

Do you have difficulty seeing the labels on medicine bottles or reading prices when you shop?

Yes

Maybe

Clear selection

Do you have difficulty writing due to vision problems?

Yes

Maybe

Clear selection

Can you recognize the faces of family or friends when you enter a room?

Yes

Maybe

Clear selection

Do you have difficulty finding the best lighting to optimize your vision in the home or office?

Yes

Maybe

Clear selection

Do you tend to sit close to the television?

Yes

Maybe

Clear selection

Do you have difficulty with glare, such as glare from a computer or television screen?

Yes

Maybe

Clear selection

Optional: Have you received a vision diagnosis such as macular degeneration or retinitis pigmentosa (RP)? If so, please list your condition here:

Optional: Please indicate the name(s) of your current optometrist and/or retina specialist:

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.

Yes

Not sure yet

Clear selection

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:

Desktop video magnifiers for the home or office

Lightweight, portable video magnifiers

Lighting for low vision

Traditional handheld magnifiers

Wearable devices

I would like advice on visual aids to assist me with the following activities (please check all that apply):

Reading (books, newspapers, magazines, mail, etc.)

Writing

Using a computer or other electronic device

Shopping

Recognizing faces

Household tasks (cooking, laundry, managing finances, etc.)

Other hobbies (knitting, sewing, playing an instrument, etc.)

Walking in unfamiliar areas

AdaptiVision is committed to protecting and respecting your privacy, and we’ll only use your personal information to administer your account and to provide the products and services you requested from us. From time to time, we would like to contact you about our products and services, as well as other content that may be of interest to you. If you consent to us contacting you for this purpose, please tick below to say how you would like us to contact you. You can unsubscribe from these communications at any time. By clicking submit below, you consent to allow AdaptiVision to store and process the personal information submitted here to provide you the content requested.

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