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Low vision assessment form 2026

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The document is an Occupational Therapy Low Vision Rehabilitation Evaluation Form designed to assess clients with visual impairments. It includes sections for client information, visual acuity measurements, background information on vision issues, daily living activities, and specific challenges faced due to low vision. The form also outlines treatment plans, recommended adaptations, and rehabilitation goals to enhance the client's functional abilities.

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Click ‘Get Form’ to open the low vision assessment form in the editor.
Begin by entering your personal information in the Client section, including your name, date of birth, address, and telephone number.
Fill in the Visual Acuity fields for both eyes. If you have visual acuity measurements from a physician, include those details.
Complete the Eye Disease Diagnosis section with any relevant information regarding your condition.
Proceed to the Background Information section. Answer questions about your vision difficulties and previous evaluations honestly.
In the Other Health Issues section, check any applicable conditions that may affect your vision rehabilitation.
Continue through each section methodically, providing detailed responses to ensure a comprehensive evaluation.

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We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

What is the difference between blindness and low vision?

A person with low vision may not recognize images at a distance or be able to differentiate between colors of similar hues. Those who are legally blind may only see light and dark images and may need to be inches away from objects to observe them properly.

What is the criteria for low vision disability?

The World Health Organization defines low vision as visual acuity between 20/70 and 20/400, with the best possible correction, or a visual field of 20 degrees or less. Blindness is defined as a visual acuity worse than 20/400, with the best possible correction, or a visual field of 10 degrees or less.

How do you assess for low vision patients?

They will use eye charts and reading materials similar to the charts used in standard eye tests, but in a different way. The Optometrist will test other aspects of your vision using different tools, including: The Snellen or LogMAR charts to test distance. Near Vision test using differing font sizes.

What qualifies as low vision disability?

The functional vision assessment (FVA) is for children with low vision. It is an assessment of how a child uses their vision in everyday life, so it is usually not done with children who are totally blind or have light perception only.

What type of disability is poor eyesight?

You have a VISUAL DISABILITY if your: vision is 20/70 (by Snellen Chart or equivalent) or worse in the better eye. field of vision is less than 20 degrees wide (by automated perimeter) in the better eye. vision cannot be improved by eyeglasses, medication, or surgery.

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What is the functional vision assessment for low vision?

Unlike regular comprehensive exams, low vision exams may not revolve around treatment of the eye disease; instead, they explore different devices and adaptive techniques to allow the patient to use the vision they have in order to achieve specific goals.

At what point is low vision a disability?

We consider you to be blind if your vision cant be corrected to better than 20/200 in your better eye. We also consider you blind if your visual field is 20 degrees or less in your better eye for a period that lasted or is expected to last at least 12 months. The duration requirement does not apply for SSI payments.

Low vision assessment form 2026

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What is the difference between blindness and low vision?

What is the criteria for low vision disability?

How do you assess for low vision patients?

What qualifies as low vision disability?

What type of disability is poor eyesight?

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What is the functional vision assessment for low vision?

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