Quality of Life Survey Form
Part 1
In general, would you say your overall health is:
Excellent
Very Good
Good
Fair
Poor
At the present time, would you say your eyesight using both eyes (with glasses or contact lenses, if you wear them) is excellent, good, fair, poor, or very poor or are you completely blind?
Excellent
Good
Fair
Poor
Very Poor
Completely Blind
How much of the time do you worry about your eyesight?
None of the time
A little of the time
Some of the time
Most of the time
All of the time?
How much pain or discomfort have you had in and around your eyes (for example, burning, itching, or aching)? Would you say it is:
None
Mild
Moderate
Severe
Very severe
Part 2
How much difficulty do you have reading ordinary print in newspapers?
No difficulty at all
A little difficulty
Moderate difficulty
Extreme difficulty
Stopped doing this because of eyesight
Stopped doing this for other reasons or not interested
How much difficulty do you have doing work or hobbies that require you to see well up close, such as cooking, sewing, fixing things around the house, or using hand tools?
No difficulty at all
A little difficulty
Moderate difficulty
Extreme difficulty
Stopped doing this because of eyesight
Stopped doing this for other reasons or not interested
Because of your eyesight, how much difficulty do you have finding something on a crowded shelf?
No difficulty at all
A little difficulty
Moderate difficulty
Extreme difficulty
Stopped doing this because of eyesight
Stopped doing this for other reasons or not interested
How much difficulty do you have reading street signs or the names of stores?
No difficulty at all
A little difficulty
Moderate difficulty
Extreme difficulty
Stopped doing this because of eyesight
Stopped doing this for other reasons or not interested
Because of your eyesight, how much difficulty do you have going down steps, stairs, or curbs in dim light or at night?
No difficulty at all
A little difficulty
Moderate difficulty
Extreme difficulty
Stopped doing this because of eyesight
Stopped doing this for other reasons or not interested
Because of your eyesight, how much difficulty do you have noticing objects off to the side while you are walking along?
No difficulty at all
A little difficulty
Moderate difficulty
Extreme difficulty
Stopped doing this because of eyesight
Stopped doing this for other reasons or not interested
Because of your eyesight, how much difficulty do you have seeing how people react to things you say?
No difficulty at all
A little difficulty
Moderate difficulty
Extreme difficulty
Stopped doing this because of eyesight
Stopped doing this for other reasons or not interested
Because of your eyesight, how much difficulty do you have picking out and matching your own clothes?
No difficulty at all
A little difficulty
Moderate difficulty
Extreme difficulty
Stopped doing this because of eyesight
Stopped doing this for other reasons or not interested
Because of your eyesight, how much difficulty do you have visiting with people in their homes, at parties, or in restaurants?
No difficulty at all
A little difficulty
Moderate difficulty
Extreme difficulty
Stopped doing this because of eyesight
Stopped doing this for other reasons or not interested
Because of your eyesight, how much difficulty do you have going out to see movies, plays, or sports events?
No difficulty at all
A little difficulty
Moderate difficulty
Extreme difficulty
Stopped doing this because of eyesight
Stopped doing this for other reasons or not interested
Are you currently driving, at least once in a while?
Yes
No
Part 3
Do you accomplish less than you would like because of your vision?
All of the time
Most of the time
Some of the time
A little of the time
None of the time
Are you limited in how long you can work or do other activities because of your vision?
All of the time
Most of the time
Some of the time
A little of the time
None of the time
How much does pain or discomfort in or around your eyes, for example, burning, itching, or aching, keep you from doing what you’d like to be doing? Would you say:
All of the time
Most of the time
Some of the time
A little of the time
None of the time
I stay home most of the time because of my eyesight.
Definitely True
Mostly True
Not Sure
Mostly False
Definitely False
I feel frustrated a lot of the time because of my eyesight.
Definitely True
Mostly True
Not Sure
Mostly False
Definitely False
I have much less control over what I do, because of my eyesight.
Definitely True
Mostly True
Not Sure
Mostly False
Definitely False
Because of my eyesight, I have to rely too much on what other people tell me.
Definitely True
Mostly True
Not Sure
Mostly False
Definitely False
I need a lot of help from others because of my eyesight.
Definitely True
Mostly True
Not Sure
Mostly False
Definitely False
I worry about doing things that will embarrass myself or others, because of my eyesight.
Definitely True
Mostly True
Not Sure
Mostly False
Definitely False
Appendix of Optional Additional Questions
How would you rate your overall health, on a scale where zero is as bad as death and 10 is best possible health?
0
How would you rate your eyesight now (with glasses or contact lens on, if you wear them), on a scale of from 0 to 10, where zero means the worst possible eyesight, as bad or worse than being blind, and 10 means the best possible eyesight?
0
Wearing glasses, how much difficulty do you have reading the small print in a telephone book, on a medicine bottle, or on legal forms?
No difficulty at all
A little difficulty
Moderate difficulty
Extreme difficulty
Stopped doing this because of eyesight
Stopped doing this for other reasons or not interested
Because of your eyesight, how much difficulty do you have figuring out whether bills you receive are accurate?
No difficulty at all
A little difficulty
Moderate difficulty
Extreme difficulty
Stopped doing this because of eyesight
Stopped doing this for other reasons or not interested
Because of your eyesight, how much difficulty do you have doing things like shaving, styling your hair, or putting on makeup?
No difficulty at all
A little difficulty
Moderate difficulty
Extreme difficulty
Stopped doing this because of eyesight
Stopped doing this for other reasons or not interested
Because of your eyesight, how much difficulty do you have recognizing people you know from across a room?
No difficulty at all
A little difficulty
Moderate difficulty
Extreme difficulty
Stopped doing this because of eyesight
Stopped doing this for other reasons or not interested
Because of your eyesight, how much difficulty do you have taking part in active sports or other outdoor activities that you enjoy (like golf, bowling, jogging, or walking)?
No difficulty at all
A little difficulty
Moderate difficulty
Extreme difficulty
Stopped doing this because of eyesight
Stopped doing this for other reasons or not interested
Because of your eyesight, how much difficulty do you have seeing and enjoying programs on TV?
No difficulty at all
A little difficulty
Moderate difficulty
Extreme difficulty
Stopped doing this because of eyesight
Stopped doing this for other reasons or not interested
Because of your eyesight, how much difficulty do you have entertaining friends and family in your home?
No difficulty at all
A little difficulty
Moderate difficulty
Extreme difficulty
Stopped doing this because of eyesight
Stopped doing this for other reasons or not interested
Do you have more help from others because of your vision?
Definitely True
Mostly True
Not Sure
Mostly False
Definitely False
Are you limited in the kinds of things you can do because of your vision?
Definitely True
Mostly True
Not Sure
Mostly False
Definitely False
Your test score is
0
Submit