 |
|
Questions |
No |
a little difficulty |
moderate difficulty |
a great deal of difficulty |
unable to do activity |
|
| 1. |
Do you have any difficulty, even with glasses, reading small print, such as labels on medicine bottles, a telephone book, food labels?
| 4 |
3 |
2 |
1 |
0 |
|
| 2. |
Do you have any difficulty, even with glasses, reading a newspaper or a book?
| 4 |
3 |
2 |
1 |
0 |
|
| 3. |
Do you have any difficulty, even with glasses, reading a large-print book or large-print newspaper or numbers on a telephone?
| 4 |
3 |
2 |
1 |
0 |
|
| 4. |
Do you have any difficulty, even with glasses, recognizing people when they are close to you?
| 4 |
3 |
2 |
1 |
0 |
|
| 5. |
Do you have any difficulty, even with glasses, seeing steps, stairs or curbs?
| 4 |
3 |
2 |
1 |
0 |
|
| 6. |
Do you have any difficulty, even with glasses, reading traffic signs, street signs, or store signs?
| 4 |
3 |
2 |
1 |
0 |
|
| 7. |
Do you have any difficulty, even with glasses, doing find handwork like sewing, knitting, crocheting, carpentry?
| 4 |
3 |
2 |
1 |
0 |
|
| 8. |
Do you have any difficulty, even with glasses, writing checks or filling out forms?
| 4 |
3 |
2 |
1 |
0 |
|
| 9. |
Do you have any difficulty, even with glasses, playing games such as bingo, dominos, card games, mah-jong?
| 4 |
3 |
2 |
1 |
0 |
|
| 10. |
Do you have any difficulty, even with glasses, taking part in sports like bowling, handball, tennis, golf?
| 4 |
3 |
2 |
1 |
0 |
|
| 11. |
Do you have any difficulty, even with glasses, cooking?
| 4 |
3 |
2 |
1 |
0 |
|
| 12. |
Do you have any difficulty, even with glasses, watching television?
| 4 |
3 |
2 |
1 |
0 |
|
| 13. |
Do you have any difficulty, even with glasses, driving during the day because of your vision?
| 4 |
3 |
2 |
1 |
0 |
|
| 14. |
Do you have any difficulty, even with glasses, driving at night because of your vision?
| 4 |
3 |
2 |
1 |
0 |
|
|
