|Low Vision Visual Functioning Questionnaire (LVVFQ)
| Gender: <.Patient_Gender.>
|
| LVVFQ Total Score = <-TOTAL->
|
|
|Questions and Answers:
|
| 1. Read newspaper or magazine articles
| <*Answer_8768*>
| 2. Read mail
|
| <*Answer_8769*>
| 3. Read menus
| <*Answer_8776*>
| 4. Read small print on package labels
| <*Answer_8770*>
| 5. Keep your place while reading
| <*Answer_8771*>
| 6. See photos
| <*Answer_8784*>
| 7. Find something on a crowded shelf
| Date Given: <.Date_Given.>
| <*Answer_8781*>
| 8. Identify medicine
| <*Answer_8778*>
| 9. Tell time
| <*Answer_8779*>
| 10. Read street signs
| <*Answer_8786*>
| 11. Read print on TV
| <*Answer_8783*>
| 12. Watch TV
| Clinician: <.Staff_Ordered_By.>
| <*Answer_8782*>
| 13. Handle finances
| <*Answer_8772*>
| 14. Take a message
| <*Answer_8773*>
| 15. Prepare meals
| <*Answer_8775*>
| 16. Use appliance dials
| <*Answer_8780*>
| 17. Groom yourself
| Location: <.Location.>
| <*Answer_8777*>
| 18. Eat and drink neatly
| <*Answer_8774*>
| 19. Get around outdoors in places you know
| <*Answer_8785*>
| 20. Adjust to bright light
| <*Answer_8787*>
|
|Information contained in this note is based on a self-report assessment
|and is not sufficient to use alone for diagnostic purposes. Assessment
|
|results should be verified for accuracy and used in conjunction with
|other diagnostic activities.
| Veteran: <.Patient_Name_Last_First.>
| SSN: <.Patient_SSN.>
| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)
|
