Vision Problems Screening
This questionnaire helps you detect vision problems. For each question, circle the value that best matches your answer.
| 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 | ||
Compile your total score. If you have a score of 34 or more, you do not have vision problems. A total between 25 and 33 indicates a mild vision handicap. Below 25, you have a moderate to severe vision handicap. Adapted from VF-14 questionnaire for visial impairment.
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The patient information leaflets are provided by Vigilance Santé Inc. This content is for information purposes only and does not in any manner whatsoever replace the opinion or advice of your health care professional. Always consult a health care professional before making a decision about your medication or treatment.