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LOW VISION INTAKE University Eye Center at Los Angeles 3916 S. Broadway, Los Angeles, CA 90037 Please PRINT clearly and neatly Section 1 Patient Information Last First Middle Initial Last four digits

How to fill out low vision intake

How to fill out a low vision intake form:

1. Begin by providing your personal information, including your name, date of birth, and contact details. This is essential for identification purposes and for the healthcare professionals to reach out to you if needed.
2. Next, indicate your current eye condition or diagnosis. This helps the healthcare provider understand your specific needs and tailor their assistance accordingly.
3. Provide a detailed medical history, including any past eye surgeries or treatments, as well as any chronic health conditions that may impact your vision.
4. Describe your visual symptoms, such as blurry vision, difficulty reading, or sensitivity to light. Be as specific as possible to ensure accurate assessment and appropriate recommendations.
5. Indicate any assistive devices or technologies you currently use or have used in the past to aid your vision. This can include magnifiers, large print materials, or screen readers.
6. Share any challenges or difficulties you face in daily activities due to your visual impairment, such as navigating unfamiliar places, cooking, or reading medication labels.
7. Provide information about your lifestyle and hobbies, as this can help the healthcare professional understand your needs and suggest adaptations or modifications to improve your quality of life.
8. Finally, make sure to ask any additional questions or concerns you may have regarding your low vision. This is your opportunity to seek further information or clarification.

Who needs low vision intake?

1. Individuals with low vision or visual impairments who require specialized assistance, support, or resources to enhance their visual function and quality of life.
2. People with eye conditions such as macular degeneration, glaucoma, diabetic retinopathy, or cataracts.
3. Individuals experiencing visual symptoms that affect their daily activities, independence, or overall well-being.
4. Those who want to explore and access assistive devices, strategies, or rehabilitation services tailored to their visual needs.
5. Older adults who may be at a higher risk of developing age-related eye conditions or experiencing age-related vision loss.
6. Any individual seeking guidance, education, or counseling related to low vision management and living with visual impairment.

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What is low vision intake?

Low vision intake is a process where individuals who have vision impairments report their condition to the relevant authority.

Who is required to file low vision intake?

Individuals with low vision are required to file low vision intake.

How to fill out low vision intake?

To fill out low vision intake, individuals need to provide information about their vision impairment and any relevant medical documentation.

What is the purpose of low vision intake?

The purpose of low vision intake is to gather data on individuals with vision impairments and provide necessary support and services.

What information must be reported on low vision intake?

Information such as the degree of vision impairment, medical diagnosis, and any treatment or assistance needed must be reported on low vision intake.