Items within the daily living tasks dependent on vision (DLTV) questionnaire
| How much difficulty do you have | No difficulty | A little difficulty | A lot of difficulty | Cannot see to do | |
|---|---|---|---|---|---|
| 1 | Distinguishing a person's features across the room | 4 | 3 | 2 | 1 |
| 2 | Noticing objects off to either side | 4 | 3 | 2 | 1 |
| 3 | Watching television programmes | 4 | 3 | 2 | 1 |
| 4 | Seeing steps and using them | 4 | 3 | 2 | 1 |
| 5 | Enjoying the scenery if out for a drive | 4 | 3 | 2 | 1 |
| 6 | Reading road signs/street names | 4 | 3 | 2 | 1 |
| 7 | Distinguishing a person's features across the street | 4 | 3 | 2 | 1 |
| 8 | Recognising seasonal changes in the garden | 4 | 3 | 2 | 1 |
| 9 | Distinguishing a person's features at arm's length | 4 | 3 | 2 | 1 |
| 10 | Pouring yourself a drink | 4 | 3 | 2 | 1 |
| 11 | Cutting up food on your plate | 4 | 3 | 2 | 1 |
| 12 | Cutting your finger nails | 4 | 3 | 2 | 1 |
| 13 | Using kitchen appliances | 4 | 3 | 2 | 1 |
| 14 | Adjusting to darkness after being in the light | 4 | 3 | 2 | 1 |
| 15 | Adjusting to the light after being in the dark | 4 | 3 | 2 | 1 |
| How confident do you feel in your ability to walk around | |||||
| Extremely | Somewhat | Barely | Not at all | ||
| 16 | In your immediate neighbourhood | 4 | 3 | 2 | 1 |
| 17 | Outside your immediate neighbourhood | 4 | 3 | 2 | 1 |
| With your near glasses on how much difficulty do you have | |||||
| No difficulty | A little difficulty | A lot of difficulty | Cannot see to do | ||
| 18 | Reading normal sized newspaper print | 4 | 3 | 2 | 1 |
| 19 | Reading newspaper headlines | 4 | 3 | 2 | 1 |
| 20 | Reading correspondence—eg, bills, letters, cards | 4 | 3 | 2 | 1 |
| 21 | Signing documents (cheques, pension book) | 4 | 3 | 2 | 1 |
| 22 | Identifying money from purse or wallet | 4 | 3 | 2 | 1 |