Vision Checklist

Circle "Yes" or "No" for each question.
 

Do you have trouble recognizing faces of friends and relatives?

Yes    No

Do you have trouble cooking, sewing, or doing things around the house because you can't see up close?

Yes    No

Do you have trouble seeing things on TV?

Yes    No

Do you have trouble reading?

Yes    No

Do you have trouble picking out and matching the color of your clothes?

Yes    No

Do lights seem dimmer than they used to?

Yes    No

Do you have trouble reading street and bus signs or the names of stores?

Yes    No

Copyright 2004.  Robert S. Stall, MD / Stall Geriatrics.  All Rights Reserved.