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Patient Email (required)
Ability to see and enjoy T.V.? Not at allA littleSometimesA lot
Taking part in recreational activities such as bowling, walking or golf? Not at allA littleSometimesA lot
Shopping? (finding what you want and paying for it) Not at allA littleSometimesA lot
Visiting friends and family? Not at allA littleSometimesA lot
Recognizing or meeting people? Not at allA littleSometimesA lot
Generally looking after your appearance? (face, hair, clothing, etc.) Not at allA littleSometimesA lot
Opening packaging? (for example, around food, medicines) Not at allA littleSometimesA lot
Reading labels or instructions on medicines? Not at allA littleSometimesA lot
Operating household appliances and the telephone? Not at allA littleSometimesA lot
Eyesight interfered with getting about outdoors? (on the pavement of crossing the street) Not at allA littleSometimesA lot
Eyesight made you go carefully to avoid falling or tripping? Not at allA littleSometimesA lot
Eyesight interfered with travelling or using transport? (bus & train) Not at allA littleSometimesA lot
Going down steps, stairs, or curbs? Not at allA littleSometimesA lot
Reading ordinary size print? (for example newspapers) Not at allA littleSometimesA lot
Getting information that you need? Not at allA littleSometimesA lot
General safety at home? Not at allA littleSometimesA lot
Spilling or breaking things? Not at allA littleSometimesA lot
General safety when out of your home? Not at allA littleSometimesA lot
Eyesight stopped you doing the things you want to do? Not at allA littleSometimesA lot
Needed help from other people because of your eyesight? Not at allA littleSometimesA lot
Embarrassed because of your eyesight? Not at allA littleSometimesA lot
Frustrated or annoyed because of your eyesight? Not at allA littleSometimesA lot
Lonely or isolated because of your eyesight? Not at allA littleSometimesA lot
Sad or low because of your eyesight? Not at allA littleSometimesA lot
Worried about your eyesight getting worse? Not at allA littleSometimesA lot
Concerned or worried about coping with everyday life? Not at allA littleSometimesA lot
Nuisance or a burden because of your eyesight? Not at allA littleSometimesA lot
Eyesight interfered with your life in general? Not at allA littleSometimesA lot
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