VISUAL IMPAIRMENT REPORT

To:	___________________________________________
	_______________________________________ (Name of Patient)
	_______________________________________ (Social Security Number)
	_______________________________________ (Phone Number)
1.	Please answer the following questions concerning your patient's impairments. a.      Date of first treatment:           ________________________________ b.      Date of most recent exam:     ________________________________ c.      Frequency of treatment:         ________________________________
2.	What is the diagnosis of your patient's condition? ______________________________________________________________________________________________________________
3.	Prognosis: ______________________________________________________________________________________________________
4.	Identify the positive clinical findings and diagnostic test results that demonstrate and/or support your diagnosis and indicate location where applicable. ______________________________________________________________________________________________________________ ______________________________________________________________________________________________________________
5.	Central visual acuity (Snellen): Distant Vision Without Glasses: With Best Correction:   R _________________ R _________________   L _________________ L _________________ Near Vision   Without Glasses: With Best Correction:   R _________________ R _________________   L _________________ L _________________ Visual efficiency with best correction:     R _________________%       L _________________%
6.	Please circle the following symptoms your patient experiences: Headaches           Eyestrain          Hallucinations         Double Vision         Blackouts Sensitivity to Light        Swelling          Eye Pain           Paralysis        Spots/Flashes        Dizziness Other __________________________________________
7.	Please estimate your patient's residual functional capacity if the patient were placed in a normal COMPETITIVE, FIVE DAY A WEEK WORK ENVIRONMENT ON A SUSTAINED BASIS. “Occasionally” means very little up to 1/3 of an 8 hour workday. “Frequently” means 1/3 to 2/3 of an 8 hour workday. In an eight-hour day, my patient can perform work activities involving:
8.	NEAR VISUAL ACUITY: _______ Constantly          _______ Frequently          _______ Occasionally          _______ Never
9.	FAR VISUAL ACUITY: _______ Constantly          _______ Frequently          _______ Occasionally          _______ Never
10.	ACCOMMODATION: _______ Constantly          _______ Frequently          _______ Occasionally          _______ Never
11.	COLOR VISION: _______ Constantly          _______ Frequently          _______ Occasionally          _______ Never
12.	DEPTH PERCEPTION: _______ Constantly          _______ Frequently          _______ Occasionally          _______ Never
13.	PERIPHERAL VISION: _______ Constantly          _______ Frequently          _______ Occasionally          _______ Never
14.	Please approximate what percentage during an eight hour workday the patient's attention and concentration would be comprimised due to his/her visual impairment and symptomatology. None      5%      10%       15%      20%      30%       40%      50%      60%       70%      ________ Other
15.	Are your patient's impairments ongoing, creating an expectation on your part that they will last at least twelve months?      ________  Yes      ________  No
16.	Will your patient sometimes need to take unscheduled breaks to rest at unpredictable intervals during an 8-hour day?           ________  Yes      ________  No If yes:  How often do you think this will happen?   ____________________
17.	How long (on average) will your patient have to rest before returning to work?   ____________________
18.	Are there any other limitations that would affect your patient's ability to work at a regular job on a sustained basis (please check all that are applicable)? ________  no driving                             ________  avoid heights                ________  no reading ________  avoid climbing                      ________  avoid ladders, ropes and scaffolds ________  avoid moving machinery       ________  no computer work        ________  avoid dust ________  no pulling                             ________  no pushing                    ________  no kneeling ________  no bending                           ________  no stooping                   ________  avoid temperature extremes
19.	In your best medical opinion, what is the earliest date the description of symptoms and limitations in this questionnaire applies? ______________________________________________________________________________________________________________
	Signature                                                             Date                                                              Specialty
	Print/Type Name
	Address

Please Return To:

Jerrold S. Zivic, Attorney at Law 850 W. Jackson Boulevard, Suite 405 Chicago, IL  60607 (312) 829-8553/Fascimile (312) 229-1653