218 (218)    MH REPORT (601.93)

|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.>)