We have enclosed this questionnaire to help us improve our knowledge about your vision problems and how they affect your quality of life. Please take as much time as you need to answer each question. Feel free to ask any family or friends if you need help reading the questions, or call us if you have any questions. All your answers are confidential. If you wear glasses or contact lenses, please answer all of the following questions as though you were wearing them.
Please Select your appropriate answers:
TASK ANALYSISPlease answer the following questions by selecting one of the following appropriate answers for each question.
- Not Applicable (NA)
- No Problem (N)
- Mild Problem (M)
- Yes, Major Problem (Y)
- Patient’s Objective (O) (This would be one of your main objectives for your low vision consultation)
TRAVELING:
Do you have Difficulty?
Distance Viewing: Do you have Difficulty?
NEAR TASKS: Do you have Difficulty?
NEAR TASKS: Do you have Difficulty?
JOB RELATED TASKS: Do you have problems?
LIGHTING CONSIDERATIONS: Do you have problems?
