ACTIVITIES OF DAILY LIVING QUESTIONNAIRE
How much are you bothered :
|
Overall decline in vision? |
little |
some |
a lot |
|
Blurry vision? |
little |
some |
a lot |
|
Glare or poor night vision? |
little |
some |
a lot |
|
Sensitivity to light? |
little |
some |
a lot |
|
Seeing rings or halos around lights? |
little |
some |
a lot |
|
Seeing double? |
little |
some |
a lot |
How much trouble do you have with your vision when you …
|
Drive during daylight hours? |
little |
some |
a lot |
|
Drive during nighttime hours? |
little |
some |
a lot |
|
See traffic or road signs? |
little |
some |
a lot |
|
Read newspapers or telephone books? |
little |
some |
a lot |
|
Read labels, price tags or medicine bottles? |
little |
some |
a lot |
|
Use a computer? |
little |
some |
a lot |
|
Hobbies? |
|
some |
a lot |
|
Look at colors? |
little |
some |
a lot |
|
Sew, cook or work around the house? |
little |
some |
a lot |
|
Play cards? |
little |
some |
a lot |
|
Watch TV? |
little |
some |
a lot |
|
Look at steps or curbs? |
little |
some |
a lot |
|
Work at your job? |
little |
some |
a lot |
|
Try to recognize people? |
little |
some |
a lot |
|
Look out of only one eye? |
little |
some |
a lot |
Please answer the following questions:
Do you have hobbies?
___Tennis ___Golf ___Cycling ___Painting ___Crafts ___ Scuba Diving
___ Travel ___RV ___ Aviation ___
Do you currently wear glasses or contacts? __________
How long have you been wearing glasses or contacts? _________
Do you are have you ever had an infection from your contacts? ______
Do you have problems wearing contacts? _______
Do you have problems with your eye glasses fogging when there is a change in temperature? _____
Do you have a problem keeping up with your glasses? _____
Would you like to be glasses and contact free after cataract surgery? _____
