Please answer these questions based on your best vision with both eyes open and wearing glasses or contact lenses if you usually do.
| 11 How would you rate your vision? (how well do you see?) Please circle one number | ||||||
|---|---|---|---|---|---|---|
| Poor | 1 | |||||
| Fair | 2 | |||||
| Good | 3 | |||||
| Very good | 4 | |||||
| Excellent | 5 | |||||
| 12 How much does your vision hinder, limit, or disable you in each of the following activities? | ||||||
| Please circle one number on each line | ||||||
| Activity | Not at all | A little bit | Some | Quite a lot | Totally disabled | Don’t do for other reasons |
| Your usual daily activities | 1 | 2 | 3 | 4 | 5 | 0 |
| Recognising people or objects across the street | 1 | 2 | 3 | 4 | 5 | 0 |
| Reading price labels in shops and supermarkets | 1 | 2 | 3 | 4 | 5 | 0 |
| Reading a magazine, newspaper or book | 1 | 2 | 3 | 4 | 5 | 0 |
| Knitting or sewing | 1 | 2 | 3 | 4 | 5 | 0 |
| Watching television | 1 | 2 | 3 | 4 | 5 | 0 |
| Daytime driving | 1 | 2 | 3 | 4 | 5 | 0 |
| Night-time driving | 1 | 2 | 3 | 4 | 5 | 0 |
| 13 How much are you hindered, limited or disabled by glare (dazzling light) in each of the following activities? | ||||||
| Please circle one number on each line | ||||||
| Activity | Not at all | A little bit | Some | Quite a lot | Totally disabled | Don’t do for other reasons |
| Your usual daily activities | 1 | 2 | 3 | 4 | 5 | 0 |
| Reading shiny paper (such as a magazine) | 1 | 2 | 3 | 4 | 5 | 0 |
| Driving towards the sun or oncoming headlights | 1 | 2 | 3 | 4 | 5 | 0 |
| Walking outside on a sunny day | 1 | 2 | 3 | 4 | 5 | 0 |
| 14 Who filled in this form? Please circle one number | ||||||
| I filled it out with no help | 1 | |||||
| I filled it out with help from family and friends | 2 | |||||
| I filled it out with help from a nurse or doctor or Bucks Association for Blind (BAB) volunteer | 3 | |||||
| Family and friends filled it out | 4 | |||||
| A nurse or doctor or BAB volunteer filled it out | 5 | |||||
| 15 Have you had a recent illness, injury, or emotional upset that has affected how you answer these questions? | ||||||
| Yes | 1 | |||||
| No | 2 | |||||
| Any comments | ||||||