Toolbox Vision Survey

Appendix B: Toolbox Vision Survey - Item and Response Option Sources

ITEM / ORIGINAL / SOURCE QUESTIONNAIRE / RESPONSE OPTIONS / ORIGINAL RESPONSE OPTIONS
A. Color Vision
A.1 Because of
your eyesight, how difficult is it for you to match the colors of your clothes? / Because of your eyesight, how much difficulty do you have picking out and matching your own clothes? / NEI-VFQ-25 / Not difficult at all;
A little bit difficult;
Somewhat difficult;
Very difficult;
Unable to do because of eyesight. / No difficulty at all; A little difficulty; moderate difficulty;
Extreme difficulty; Stopped doing this because of your eyesight; Stopped doing this for other reasons or not interested in doing this.
A.2 How difficult is it for you to recognize colors? / How much problem do you have in recognizing colors? / QOLVFQ / Not difficult at all;
A little bit difficult;
Somewhat difficult; Very difficult; Unable to do. / Not at all;
Quite a lot;
Very much.
A.3 How difficult is it for you to distinguish between colors? / I have difficulty distinguishing between colors. / VAQ / Not difficult at all;
A little bit difficult;
Somewhat difficult;
Very difficult; Unable to do. / Never;
Rarely; Sometimes; Often;
Always.
B. Low Lumi-nance Vision
B.1 How difficult is it for you to see in bright sunlight? / 1 - Do you have difficulty seeing in bright sunlight? / Low Luminance Questionnaire (version 1) / Not difficult at all;
A little bit difficult;
Somewhat difficult;
Very difficult; Unable to see in bright sunlight. / No difficulty at all; A little difficulty;
Some difficulty;
A lot of difficulty; Completely blind under these conditions;
Stopped going out in bright sunlight because of your vision; Stopped for other reasons.
B.2 How difficult is it for you to see in fluorescent lighting such as in stores and offices? / Do you have difficulty seeing in fluorescent lighting, like that found in stores and offices? / Low Luminance Questionnaire (version 1) / Not difficult at all;
A little bit difficult;
Somewhat difficult;
Very difficult; Unable to see in fluorescent lighting. / No difficulty at all; A little difficulty;
Some difficulty;
A lot of difficulty; Completely blind under these conditions;
Stopped going to places with fluorescent lighting because of your vision; Stopped for other reasons.
B.3 How difficult is it for you to see at night? / Do you have difficulty seeing at night? / Low Luminance Questionnaire (version 1) / Not difficult at all;
A little bit difficult;
Somewhat difficult;
Very difficult; Unable to see in at night. / No difficulty at all; A little difficulty;
Some difficulty;
A lot of difficulty; Completely blind under these conditions.
B.4 How difficult is it for you to see street signs at night when you are in a car? / During the past 3 months, have you tried to read street signs at night either when driving or when you are a passenger in a car?
Would you say that you read street signs at night with (PLEASE CHECK ONLY ONE ANSWER). / ADVS
ADVS / Not difficult at all;
A little bit difficult;
Somewhat difficult;
Very difficult; Unable to see street signs from a car at night. / Yes;
No.
No difficulty at all; A little difficulty;
Moderate difficulty;
Extreme difficulty.
B.5 How difficult is it for you to see when you go from a lighted area into a dark place? / How much difficulty do you have getting used to the dark when you move from a lighted area into dark place, like walking into a dark movie theatre? / NEI-RQL-42 / Not difficult at all;
A little bit difficult;
Somewhat difficult;
Very difficult; Unable to see when going from a lighted area into a dark place. / No difficulty at all; A little difficulty; Moderate difficulty;
A lot of difficulty.
B.6 How difficult is it for you to read in dim light? / Do you have difficulty reading menus in dimly lit restaurants? / Low Luminance Questionnaire (version 1) / Not difficult at all;
A little bit difficult;
Somewhat difficult;
Very difficult; Unable to read in dim light; Unable to read in dim light because of another reason. / No difficulty at all; A little difficulty; Some difficulty;
A lot of difficulty; Completely blind under these conditions;
Stopped doing this because of your vision;
Stopped for other reasons;
Never reads menus.
C. DISTANCE VISION
C.1 Because of your eyesight, how difficult is it for you to go up or down steps, stairs, or curbs? / In the PAST MONTH, how much has YOUR EYESIGHT INTERFERED with the following activities: Going down steps, stairs, or curbs? / IVI / Not difficult at all; A little bit difficult; Somewhat difficult;
Very difficult; Unable to do because of eyesight;
Unable to go up or down steps, stairs, or curbs because of another reason. / Not at all;
Hardly at all;
A little;
A fair amount;
A lot;
Can't do because of eyesight;
Don't do this for other reasons.
C.2 Because of your eyesight, how difficult is it for you to get around outdoors? / In the PAST MONTH, how much has YOUR EYESIGHT INTERFERED with the following activities: How much has your eyesight interfered with getting about outdoors? (on the pavement or crossing the street) / IVI / Not difficult at all; A little bit difficult; Somewhat difficult;
Very difficult; Unable to do because of eyesight;
Unable to get around outdoors because of another reason. / Not at all;
Hardly at all;
A little;
A fair amount;
A lot;
Can't do because of eyesight;
Don't do this for other reasons.
C.3 Because of your eyesight, how difficult is it for you to see moving objects? / How much problem do you have with seeing moving objects? / LVQOL / Not difficult at all; A little bit difficult; Somewhat difficult;
Very difficult; Unable to do because of eyesight. / Scale: 5-1 (5=None;
4-2 Moderate;
1- great).
C.4 Because of your eyesight, how difficult is it for you to see street signs? / How much problem do you have with seeing street signs? / LVQOL / Not difficult at all; A little bit difficult; Somewhat difficult;
Very difficult; Unable to do because of eyesight. / Scale: 5-1 (5=None;
4-2 Moderate;
1- great).
C.5 Because of your eyesight, how difficult is it for you to see television? / How much problem do you have with seeing the television? / LVQOL / Not difficult at all; A little bit difficult; Somewhat difficult;
Very difficult; Unable to do because of eyesight;
Unable to see television because of another reason. / Scale: 5-1 (5=None;
4-2 Moderate;
1- great).
C.6 Because of your eyesight, how difficult is it for you to drive at night? / Would you say that you drive at night with (pick level of difficulty from none to extreme). / ADVS / Not difficult at all; A little bit difficult; Somewhat difficult;
Very difficult; Unable to do because of eyesight;
Unable to drive at night because of another reason. / No difficulty at all; A little difficulty; Moderate difficulty;
Extreme difficulty.
C.7 Because of your eyesight, how difficult is it for you to drive due to glare from oncoming headlights? / During the last month, how much trouble have you had with driving when there is glare from oncoming headlights? / RSVP / Not difficult at all; A little bit difficult; Somewhat difficult;
Very difficult; Unable to do because of eyesight;
Unable to drive because of another reason. / With glasses, With Contact Lenses; With No Correction:
1-No difficulty at all;
2-A little difficulty; 3-Moderate difficulty;
4-Severe difficulty;
5-So much difficulty that I did not do the activity with this type of correction;
6-Never did the activity for other reasons (not related to vision).
C.8 Because of your eyesight, how difficult is it for you to recognize people from across a room? / Because of your vision do you have problems in recognizing a person in a crowded room? / QOLVFQ / Not difficult at all; A little bit difficult; Somewhat difficult;
Very difficult; Unable to do because of eyesight. / Not at all;
Quite a lot;
Very much.
D. General Vision
Distance Vision
D.1 In general, how would you rate your eyesight for seeing things at a distance? / At the present time, would you say your eyesight using both eyes (with glasses or contact lenses, if you wear them) is excellent, good, fair, poor, or verypoor or are you completely blind?
Because of your eyesight, how much difficulty do you have going out to see movies, plays, or sports events?
How much difficulty do you have reading street signs or the names of stores? / NEI-VFQ-25
NEI-VFQ-25
NEI-VFQ-25 / Poor;
Fair;
Good;
Very Good; Excellent. / Excellent;
Good;
Fair;
Poor;
Very poor; Completely blind.
No difficulty at all; A little difficulty; moderate difficulty;
extreme difficulty; stopped doing this because of your eyesight; stopped doing this for other reasons or not interested in doing this.
No difficulty at all; A little difficulty; moderate difficulty;
extreme difficulty; stopped doing this because of your eyesight; stopped doing this for other reasons or not interested in doing this.
D.2 How much of a problem do you have with seeing things at a distance
during the day? / At the present time, would you say your eyesight using both eyes (with glasses or contact lenses, if you wear them) is excellent, good, fair, poor, or verypoor or are you completely blind?
During the past 3 months, have you tried to read street signs in daylight?
Would you say that you read street signs in daylight with (PLEASE CHECK ONLY ONE ANSWER).
Is it because of visual problems that you do not read street signs in daylight? / NEI-VFQ-25
ADVS
ADVS
ADVS / No problem at all;
A little bit of a problem;
Somewhat of a problem;
Very much of a problem;
Unable to see. / Excellent;
Good;
Fair;
Poor;
Very poor; Completely blind.
Yes;
No.
No difficulty at all; A little difficulty; Moderate difficulty;
Extreme difficulty.
Yes;
No.
D.3 How much of a problem do you have with seeing things at a distance
at nighttime? / At the present time, would you say your eyesight using both eyes (with glasses or contact lenses, if you wear them) is excellent, good, fair, poor, or verypoor or are you completely blind?
How much problem do you have with your vision at night inside the house?
During the past 3 months, have you tried to read street signs at night either when driving or when you are a passenger in a car?
Would you say that you read street signs at night with: (PLEASE CHECK ONLY ONE ANSWER)
Is it because of your visual problems that you do not read street signs at night? / NEI-VFQ-25
LVQOL
ADVS
ADVS
ADVS / No problem at all;
A little bit of a problem;
Somewhat of a problem;
Very much of a problem;
Unable to see. / Excellent;
Good;
Fair;
Poor;
Very poor; Completely blind.
Scale: 5-1 (5=None, 4-2 Moderate, 1- great)
Yes;
No.
No difficulty at all; A little difficulty; Moderate difficulty; Extreme difficulty.
Yes;
No.
Near Vision
D.4 In general, how would you rate your eyesight for seeing things
close up? / At the present time, would you say your eyesight using both eyes (with glasses or contact lenses, if you wear them) is excellent, good, fair, poor, or verypoor or are you completely blind?
How much difficulty do you have doing work or hobbies that require you to see up close, such as cooking, fixing things around the house, sewing, using hand tools, or working with a computer?
How much difficulty do you have doing work or hobbies that require you to see well up close, such as cooking, sewing, fixing things around the house, or using hand tools?
Do you have any difficulty, even with glasses, recognizing people wihen they are close to you?
I have difficulty doing any type of work which requires me to see well up close. / NEI-VFQ-25
NEI-RQL-42
NEI-VFQ-25
VF14
VAQ / Poor;
Fair;
Good;
Very Good; Excellent. / Excellent;
Good;
Fair;
Poor;
Very poor; Completely blind.
No difficulty at all; A little difficulty; Moderate difficulty;
A lot of difficulty; Never try to do these activities because of vision; Never do these activities for other reasons.
No difficulty at all; A little difficulty; moderate difficulty; extreme difficulty; stopped doing this because of your eyesight; stopped doing this for other reasons or not interested in doing this.
Yes; No; NA.
If yes, how much difficulty do you currently have: A little ; A moderate amount; A great deal; Are you unable to do the activity.
Never;
Rarely; Sometimes; Often;
Always.
D.5 How much of a problem do you have with seeing things close up
during the day? / At the present time, would you say your eyesight using both eyes (with glasses or contact lenses, if you wear them) is excellent, good, fair, poor, or verypoor or are you completely blind? / NEI-VFQ-25 / No problem at all;
A little bit of a problem;
Somewhat of a problem;
Very much of a problem;
Unable to see. / Excellent;
Good;
Fair;
Poor;
Very poor; Completely blind.
D.6 How much of a problem do you have with seeing things close up
at nighttime? / At the present time, would you say your eyesight using both eyes (with glasses or contact lenses, if you wear them) is excellent, good, fair, poor, or verypoor or are you completely blind? / NEI-VFQ-25 / No problem at all;
A little bit of a problem;
Somewhat of a problem;
Very much of a problem;
Unable to see. / Excellent;
Good;
Fair;
Poor;
Very poor; Completely blind.
E. Near Vision
E.1 Because of your eyesight, how difficult is it for you to read a newspaper or book? / Do you have any difficulty, even with glasses, reading a newspaper or a book? / VF14 / Not difficult at all; A little bit difficult; Somewhat difficult;
Very difficult; Unable to do because of eyesight;
Unable to read a newspaper or book because of another reason. / Yes;
No;
NA.
If yes, how much difficulty do you currently have:
A little ;
A moderate amount;
A great deal;
Are you unable to do the activity.
E.2 Because of your eyesight, how difficult is it for you to find an item on a crowded shelf? / Because of your eyesight, how much difficulty do you have finding something on a crowded shelf? / NEI-VFQ-25 / Not difficult at all;
A little bit difficult; Somewhat difficult;
Very difficult; Unable to do because of eyesight;
Unable to find an item on a crowded shelf because of another reason. / No difficulty at all; A little difficulty; Moderate difficulty;
Extreme difficulty; Stopped doing this because of your eyesight;
Stopped doing this for other reasons or not interested in doing this.
E.3 How difficult is it for you to see a sign when there are other signs around it? / I have trouble locating a sign when it is surrounded by a lot of other signs. / VAQ / Not difficult at all; A little bit difficult; Somewhat difficult;
Very difficult; Unable to do because of eyesight; / Never;
Rarely; Sometimes; Often;
Always.
E.4 How difficult is it for you to read labels or instructions? / In the PAST MONTH, how much has YOUR EYESIGHT INTERFERED with the following activities: Reading labels or instructions on medicines? / IVI / Not difficult at all; A little bit difficult; Somewhat difficult;
Very difficult; Unable to do because of eyesight;
Unable to read labels or instructions because of another reason. / Not at all;
Hardly at all;
A little;
A fair amount;
A lot;
Can't do because of eyesight;
Don't do this for other reasons.
E.5 Because of your eyesight, how difficult is it for you to use a computer? / Over the last 2 weeks, how limited were you in doing the following activities because of you dry eyes? Working on a computer. / IDEEL / Not difficult at all; A little bit difficult; Somewhat difficult;
Very difficult; Unable to do because of eyesight;
Unable to use a computer because of another reason. / I did not do this activity for reasons other than my dry eyes; NA;
None of the time; A little of the time; Some of the time; Most of the time; All of the time;
I can no longer do this activity due to my dry eyes.
E.6 Because of your eyesight, how difficult is it for you to operate a household appliance like a microwave, a washing machine or a toaster oven? / In the PAST MONTH, how much has YOUR EYESIGHT INTERFERED with the following activities: Operating household appliances and the telephone? / IVI / Not difficult at all; A little bit difficult; Somewhat difficult;
Very difficult; Unable to do because of eyesight;
Unable to operate a household appliance because of another reason. / Not at all;
Hardly at all;
A little;
A fair amount;
A lot;
Can't do because of eyesight;
Don't do this for other reasons.
E.7 Because of your eyesight, how difficult is it for you to write? / Would you say that you write checks with (no difficulty to extreme)? / ADVS / Not difficult at all; A little bit difficult; Somewhat difficult;
Very difficult; Unable to do because of eyesight;
Unable to write because of another reason. / No visual difficulty at all;
A little difficulty because of vision; Moderate difficulty because of vision;
Extreme difficulty because of vision.
E.8 Because of your eyesight, how difficult is it for you to do work or hobbies that require you to see up close such as cooking, or fixing things around the house? / How much difficulty do you have doing work or hobbies that require you to see up close, such as cooking, fixing things around the house, sewing, using hand tools, or working with a computer? / NEI-RQL-42 / Not difficult at all;
A little bit difficult; Somewhat difficult;
Very difficult; Unable to do because of eyesight;
Unable to do work or hobbies that require me to see up close because of another reason. / No difficulty at all; A little difficulty; Moderate difficulty;
A lot of difficulty; Never try to do these activities because of vision; Never do these activities for other reasons.
E.9 How difficult is it for you to recognize people when they are standing or sitting near you? / Do you have any difficulty, even with glasses, recognizing people when they are close to you? / VF14 / Not difficult at all;
A little bit difficult; Somewhat difficult;
Very difficult; Unable to do because of eyesight. / Yes;
No; NA.
If yes, how much difficulty do you currently have:
A little ;
A moderate amount;
A great deal;
Are you unable to do the activity.
F: Ocular Symptoms
F.1 In the last 7 days, how much of a problem did you have with glare from bright lights? / How much problem do you have with glare (e.g. dazzled by car light or the sun)? / LVQOL / No problem at all;
A little bit of a problem;
Somewhat of a problem;