MARCUS A. EAST, M.D.
JOHN G. DODD, D.O.
RYAN W. LAPOUR, M.D.
ADAM T. SHUPE, O.D.
VISION CHECK FORM
Patient Name:
Birthdate:  
PLEASE MARK YOUR RESPONSE ON EACH LINE
Have you been bothered by:
Answer
Comments
Overall decline in vision
Blurry Vision
Glare or poor night vision
Sensitivity to light
Seeing rings or halos around lights
Seeing double
Have you noticed a decrease in your vision
when you:

Answer

Comments
Driving during daylight hours
Driving during night time hours
See traffic or road signs
Read newspapers or telephone books
Read labels, price tags or medicine bottles
Use a computer
Do fine handwork or hobbies
Look at colors
Sew, cook or work around the house
Play cards
Watch TV
Look at steps or curbs
Work at your job
Try to recognize people
Look out of only one eye
Other:
Signature of Patient or Patient's Legal Representative
Date
655 Medical Center Dr. NE
Salem, Oregon 97301
503.581.5287
Fax 503.386.1377
mceyeclinic.com