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Children’s Vision Programs
Adult Vision Programs
Certified Vision Screening Training Dates & Locations
Resources
- Family/Individual Vision Resources
- Professionals Vision Health Resources
Vision Care Financial Assistance Programs
- Children’s Vision Voucher Application and Criteria
- Adult Vision Voucher Applications and Criteria
Your Sight
Your Child’s Sight
Eye Diseases & Conditions

Adult Vision Programs

Adult Vision Health Risk Assessment

Name*
First Last
Phone*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Email*
Birthdate*
Race/Ethnicity
Gender
Do you have vision health insurance?*
- Yes
- No
- Unsure
What year was your last eye exam? If unknown, leave blank.
Risk Assessment Questions
This vision assessment will help to determine whether you are at risk of age-related eye disease.
Do you have blood relatives with glaucoma?*
- Yes
- No
- Not Sure
Has a doctor treated you for or said you have glaucoma?*
- Yes
- No
- Not Sure
Have you ever had an eye injury or eye surgery?*
- Yes
- No
Have you noticed a change in vision in the last 12 months?*
- Yes
- No
Do you have constant pain in or around your eyes?*
- Yes
- No
Are you black, Hispanic or Latino, and age 40 and older?*
- Yes
- No
Are you age 60 or older?*
- Yes
- No
Was your last dilated eye exam more than two years ago?*
- Yes
- No
- Unsure
Do you have diabetes?*
- Yes
- No
If you do have diabetes, was your last dilated eye exam more than one year ago?
- Yes
- No
- Unsure
Do you have any questions for Prevent Blindness Wisconsin staff about vision health?
Would you like to sign up for our monthly FY-Eye Newsletter?
- Yes
CAPTCHA

Children’s Vision Programs
Adult Vision Programs
Certified Vision Screening Training Dates & Locations
Resources
- Family/Individual Vision Resources
- Professionals Vision Health Resources
Vision Care Financial Assistance Programs
- Children’s Vision Voucher Application and Criteria
- Adult Vision Voucher Applications and Criteria
Your Sight
Your Child’s Sight
Eye Diseases & Conditions

Risk Assessment Questions