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Get Started With Our Self-Assessment

Ocutech often receive inquiries from individuals seeking guidance on selecting the right bioptics for their unique needs. While the ultimate decision should be based on the recommendations of your low vision specialist, this questionnaire can serve as a helpful starting point. It may assist you in identifying a suitable Ocutech product and give you an initial understanding of how bioptic devices could benefit you.

Please note that the report you'll receive is based on your provided responses and is not a formal prescription. Our team will review your responses, and you can expect to receive a report and suggestions within five working days.

Ocutech does not share patient info and are HIPPAA compliant

"(Required)" indicates required fields.

Self-Assessment

First Name(Required)

Last Name(Required)

Email(Required)

1. What is your age?

2. Number of years of visual impairment?

3. Has your vision worsened in the last year?(Required)

Yes

4. What is the cause of your reduced vision?(Required)

5. What is the visual acuity of your right eye (with eyeglasses or contacts if they help)?(Required)

6. Do you wear glasses or contacts to achieve this visual acuity?(Required)

Yes

7. What is the visual acuity of your left eye (with eyeglasses or contacts if they help)?(Required)

8. Do you wear glasses or contacts to achieve this visual acuity?

Yes

9. Which is your dominant eye? It may NOT be your better-seeing eye.(Required)

Right eye is dominant

Left eye is dominant

I cannot determine which eye is dominant

10. What is the furthest distance that you can recognize a family member's face by their features? (with both eyes open)

11. Describe your vision - is it:(Required)

Just blurry

Just foggy (cloudy)

Both blurry and foggy

12. When looking through a pair of binoculars, can you see much better at a distance?(Required)

Yes

Haven't tried

13. What vision goals are you hoping to improve - Seeing at a DISTANCE?(Required)

14. What vision goals are you hoping to improve - Seeing at MID RANGE?(Required)

15. What vision goals are you hoping to improve - Seeing at SHORT RANGE?(Required)

Reading Labels and Prices

Extended Reading

Sewing and Other Handicrafts

Other

16. What other short range vision goals would you hope to improve?

17. Is there anything else you'd like to tell us?

18. Do you need a referral to a low vision specialist?(Required)

Yes

City

State / Province / Region

ZIP / Postal Code

Country

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Your feedback will help us continue to improve our services and support for individuals like you who are seeking enhanced vision solutions.

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