| (1) The following questions ask about problems with your eyesight you might have had during the last month. For each question please give one answer. Do you have difficulty, even with glasses, in doing one of the following activities: (please circle one number on each line) | |||||
| No difficulty | A little difficulty | Moderate difficulty | Quite a bit of difficulty | A lot of difficulty | |
| (a) Reading newspapers? | 1 | 2 | 3 | 4 | 5 |
| (b) Reading numbers in a telephone directory? | 1 | 2 | 3 | 4 | 5 |
| (c) Reading prices? | 1 | 2 | 3 | 4 | 5 |
| (d) Reading labels? | 1 | 2 | 3 | 4 | 5 |
| (e) Recognising other people? | 1 | 2 | 3 | 4 | 5 |
| (f) Seeing steps? | 1 | 2 | 3 | 4 | 5 |
| (g) Seeing cracks in the pavement? | 1 | 2 | 3 | 4 | 5 |
| (h) Seeing road signs? | 1 | 2 | 3 | 4 | 5 |
| (2) During the past month, how much have you been bothered by... (please circle one number on each line) | |||||
| Not at all | A little | Moderately | Quite a bit | Extremely | |
| (a) Difficulty seeing at night? | 1 | 2 | 3 | 4 | 5 |
| (b) Hazy or blurry vision? | 1 | 2 | 3 | 4 | 5 |
| (c) Difficulty adapting to bright lights (eg, going out on a bright day)? | 1 | 2 | 3 | 4 | 5 |
| (d) Difficulty adapting to dim light (eg, entering a darkened room)? | 1 | 2 | 3 | 4 | 5 |
| (e) Pain or discomfort in your treated/artificial eye? | 1 | 2 | 3 | 4 | 5 |
| (f) Watering of your treated/artificial eye? | 1 | 2 | 3 | 4 | 5 |
| (g) Stickiness or discharge of your treated/artificial eye? | 1 | 2 | 3 | 4 | 5 |
| (h) The appearance of your treated/artificial eye | 1 | 2 | 3 | 4 | 5 |
| (i) Other people noticing your treated/artificial eye | 1 | 2 | 3 | 4 | 5 |
| (3) In general, would you say your vision is: (please circle one number) | |
| Excellent | 1 |
| Very good | 2 |
| Good | 3 |
| Fair | 4 |
| Poor | 5 |
|
(4) How would you rate your current vision on a scale from 0 to 100, if 100 is excellent vision and if 0 is blindness_______(Please enter a number between 0 and 100)? (5) During the past month, how often have you felt self conscious about your treated/artificial eye? (please circle one number on each line) | |
| None of the time | 1 |
| A little of the time | 2 |
| Some of the time | 3 |
| Most of the time | 4 |
| All of the time | 5 |
| (6) How satisfied are you with the appearance of your treated/artificial eye? (Please circle one number) | |
| Very satisfied | 4 |
| Somewhat satisfied | 3 |
| Somewhat dissatisfied | 2 |
| Very dissatisfied | 1 |
| (7) What were some of the best things about your treatment? | |
| (8) What were some of the worst things about your treatment? | |
| (9) How could we improve upon the treatment you received | |
| (10) Is there anything else which has not been covered and you would like to say? | |