VFQ-25 Questionnaire

(READ CATEGORIES AS NEEDED)

(Circle One On Each Line)

All of
the time

Most of
the time

Some of
the time

A little of
the time

None of
the time

Do you have more help from others
because of your vision? ................................................

Are you limited in the kinds of things you can do
because of your vision? ................................................

PB/IA

National Eye Institute
Visual Functioning Questionnaire - 25
(VFQ-25)
version 2000
(INTERVIEWER ADMINISTERED FORMAT)

January 2000

Instructions:

I'm going to read you some statements about problems which involve your vision or feelings that you have about your vision condition. After each question I will read you a list of possible answers. Please choose the response that best describes your situation.

Please answer all the questions as if you were wearing your glasses or contact lenses (if any).

Please take as much time as you need to answer each question. All your answers are confidential. In order for this survey to improve our knowledge about vision problems and how they affect your quality of life, your answers must be as accurate as possible. Remember, if you wear glasses or contact lenses for a particular activity, please answer all of the following questions as though you were wearing them.

Visual Functioning Questionnaire - 25

PART 1 - GENERAL HEALTH AND VISION

In general, would you say your overall health is*:

	(Circle One)
READ CATEGORIES:	Excellent ...................................	1
	Very Good ................................	2
	Good ........................................	3
	Fair ..........................................	4
	Poor .........................................	5

______________________
* Skip Question 1 when the VFQ-25 is administered at the same time as the SF-36 or RAND 36-Item Health Survey 1.0

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 very poor or are you completely blind ?

	(Circle One)
READ CATEGORIES:	Excellent ...................................	1
	Good ........................................	2
	Fair ..........................................	3
	Poor .........................................	4
	Very Poor .................................	5
	Completely Blind .......................	6

How much of the time do you worry about your eyesight ?

	(Circle One)
READ CATEGORIES:	None of the time ........................	1
	A little of the time ......................	2
	Some of the time ........................	3
	Most of the time ........................	4
	All of the time? ..........................	5

How much pain or discomfort have you had in and around your eyes (for example, burning, itching, or aching) ? Would you say it is:

	(Circle One)
READ CATEGORIES:	None ........................................	1
	Mild .........................................	2
	Moderate ..................................	3
	Severe, or .................................	4
	Very severe? .............................	5

PART 2 - DIFFICULTY WITH ACTIVITIES

The next questions are about how much difficulty, if any, you have doing certain activities wearing your glasses or contact lenses if you use them for that activity.

How much difficulty do you have reading ordinary print in newspapers ? Would you say you have:

(READ CATEGORIES AS NEEDED)
	(Circle One)
	No difficulty at all ..................................................	1
	A little difficulty .....................................................	2
	Moderate difficulty .................................................	3
	Extreme difficulty ...................................................	4
	Stopped doing this because of your eyesight ..............	5
	Stopped doing this for other reasons or not interested in doing this ........................................	6

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 ? Would you say:

(READ CATEGORIES AS NEEDED)
	(Circle One)
	No difficulty at all ..................................................	1
	A little difficulty .....................................................	2
	Moderate difficulty .................................................	3
	Extreme difficulty ...................................................	4
	Stopped doing this because of your eyesight ..............	5
	Stopped doing this for other reasons or not interested in doing this ........................................	6

Because of your eyesight, how much difficulty do you have finding something on a crowded shelf ?

(READ CATEGORIES AS NEEDED)
	(Circle One)
	No difficulty at all ..................................................	1
	A little difficulty .....................................................	2
	Moderate difficulty .................................................	3
	Extreme difficulty ...................................................	4
	Stopped doing this because of your eyesight ..............	5
	Stopped doing this for other reasons or not interested in doing this ........................................	6

How much difficulty do you have reading street signs or the names of stores ?

(READ CATEGORIES AS NEEDED)
	(Circle One)
	No difficulty at all ..................................................	1
	A little difficulty .....................................................	2
	Moderate difficulty .................................................	3
	Extreme difficulty ...................................................	4
	Stopped doing this because of your eyesight ..............	5
	Stopped doing this for other reasons or not interested in doing this .......................................	6

Because of your eyesight, how much difficulty do you have going down steps, stairs, or curbs in dim light or at night ?

(READ CATEGORIES AS NEEDED)
	(Circle One)
	No difficulty at all ..................................................	1
	A little difficulty .....................................................	2
	Moderate difficulty .................................................	3
	Extreme difficulty ...................................................	4
	Stopped doing this because of your eyesight ..............	5
	Stopped doing this for other reasons or not interested in doing this .......................................	6

Because of your eyesight, how much difficulty do you have noticing objects off to the side while you are walking along ?

(READ CATEGORIES AS NEEDED)
	(Circle One)
	No difficulty at all ..................................................	1
	A little difficulty .....................................................	2
	Moderate difficulty .................................................	3
	Extreme difficulty ...................................................	4
	Stopped doing this because of your eyesight ..............	5
	Stopped doing this for other reasons or not interested in doing this .......................................	6

Because of your eyesight, how much difficulty do you have seeing how people react to things you say ?

(READ CATEGORIES AS NEEDED)
	(Circle One)
	No difficulty at all ..................................................	1
	A little difficulty .....................................................	2
	Moderate difficulty .................................................	3
	Extreme difficulty ...................................................	4
	Stopped doing this because of your eyesight ..............	5
	Stopped doing this for other reasons or not interested in doing this ........................................	6

Because of your eyesight, how much difficulty do you have picking out and matching your own clothes ?

(READ CATEGORIES AS NEEDED)
	(Circle One)
	No difficulty at all ..................................................	1
	A little difficulty .....................................................	2
	Moderate difficulty .................................................	3
	Extreme difficulty ...................................................	4
	Stopped doing this because of your eyesight ..............	5
	Stopped doing this for other reasons or not interested in doing this ........................................	6

Because of your eyesight, how much difficulty do you have visiting with people in their homes, at parties, or in restaurants ?

(READ CATEGORIES AS NEEDED)
	(Circle One)
	No difficulty at all ..................................................	1
	A little difficulty .....................................................	2
	Moderate difficulty .................................................	3
	Extreme difficulty ...................................................	4
	Stopped doing this because of your eyesight ..............	5
	Stopped doing this for other reasons or not interested in doing this ........................................	6

Because of your eyesight, how much difficulty do you have going out to see movies, plays, or sports events ?

(READ CATEGORIES AS NEEDED)
	(Circle One)
	No difficulty at all ..................................................	1
	A little difficulty .....................................................	2
	Moderate difficulty .................................................	3
	Extreme difficulty ...................................................	4
	Stopped doing this because of your eyesight ..............	5
	Stopped doing this for other reasons or not interested in doing this ........................................	6

Now, I'd like to ask about driving a car. Are you currently driving, at least once in a while ?

(Circle One)
Yes ..........................................................	1	Skip To Q 15c
No ...........................................................	2

15a. IF NO, ASK: Have you never driven a car or have you given up driving ?

(Circle One)
Never drove ..............................................	1	Skip To Part 3, Q 17
Gave up ....................................................	2

15b. IF GAVE UP DRIVING: Was that mainly because of your eyesight, mainly for some other reason, or because of both your eyesight and other reasons ?

(Circle One)
Mainly eyesight ..........................................	1	Skip To Part 3, Q 17
Mainly other reasons ..................................	2	Skip To Part 3, Q 17
Both eyesight and other reasons ...................	3	Skip To Part 3, Q 17

15c. IF CURRENTLY DRIVING: How much difficulty do you have driving during the daytime in familiar places ? Would you say you have:

(Circle One)
No difficulty at all ......................................	1
A little difficulty .........................................	2
Moderate difficulty .....................................	3
Extreme difficulty .......................................	4

How much difficulty do you have driving at night ? Would you say you have:

(READ CATEGORIES AS NEEDED)
	(Circle One)
	No difficulty at all ......................................................	1
	A little difficulty .........................................................	2
	Moderate difficulty .....................................................	3
	Extreme difficulty .......................................................	4
	Have you stopped doing this because of your eyesight .......................................................	5
	Have you stopped doing this for other reasons or are you not interested in doing this .........................	6

16a. How much difficulty do you have driving in difficult conditions, such as in bad weather, during rush hour, on the freeway, or in city traffic ? Would you say you have:

(READ CATEGORIES AS NEEDED)
	(Circle One)
	No difficulty at all ......................................................	1
	A little difficulty .........................................................	2
	Moderate difficulty .....................................................	3
	Extreme difficulty .......................................................	4
	Have you stopped doing this because of your eyesight .......................................................	5
	Have you stopped doing this for other reasons or are you not interested in doing this .........................	6

PART 3: RESPONSES TO VISION PROBLEMS

The next questions are about how things you do may be affected by your vision. For each one, I'd like you to tell me if this is true for you all, most, some, a little, or none of the time.

		(Circle One On Each Line)
READ CATEGORIES:		All of the time	Most of the time	Some of the time	A little of the time	None of the time
17.	Do you accomplish less than you would like because of your vision ? ...................................................................................	1	2	3	4	5

18.	Are you limited in howlong you can work or do other activities because of your vision ? ............................................................	1	2	3	4	5

19.	How much does pain or discomfort in or around your eyes, for example, burning, itching, or aching, keep you from doing what you'd like to be doing ? Would you say: .....................................	1	2	3	4	5

For each of the following statements, please tell me if it is definitely true, mostly true, mostly false, or definitely false for you or you are not sure.

		(Circle One On Each Line)
		Definitely True	Mostly True	Not Sure	Mostly False	Definitely False
20.	I stay home most of the time because of my eyesight .....................	1	2	3	4	5

21.	I feel frustrated a lot of the time because of my eyesight ................	1	2	3	4	5

22.	I have much less control over what I do, because of my eyesight .......................................................	1	2	3	4	5

23.	Because of my eyesight, I have to rely too much on what other people tell me ..............	1	2	3	4	5

24.	I need a lot of help from others because of my eyesight ................	1	2	3	4	5

25.	I worry about doing things that will embarrass myself or others, because of my eyesight .......................................................	1	2	3	4	5

That's the end of the interview. Thank you very much for your time and your help.

Appendix of Optional Additional Questions

SUBSCALE: GENERAL HEALTH

A 1. How would you rate your overall health, on a scale where zero is as bad as death and 10 is best possible health ?

(Circle One)
0	1	2	3	4	5	6	7	8	9	10
Worst										Best

SUBSCALE: GENERAL VISION

A 2. How would you rate your eyesight now (with glasses or contact lens on, if you wear them), on a scale of from 0 to 10, where zero means the worst possible eyesight, as bad or worse than being blind, and 10 means the best possible eyesight ?

(Circle One)
0	1	2	3	4	5	6	7	8	9	10
Worst										Best

SUBSCALE: NEAR VISION

A 3. Wearing glasses, how much difficulty do you have reading the small print in a telephone book, on a medicine bottle, or on legal forms ? Would you say:

(READ CATEGORIES AS NEEDED)
	(Circle One)
	No difficulty at all ......................................................	1
	A little difficulty .........................................................	2
	Moderate difficulty .....................................................	3
	Extreme difficulty .......................................................	4
	Stopped doing this because of your eyesight ..................	5
	Stopped doing this for other reasons or not interested in doing this ............................................	6

A 4. Because of your eyesight, how much difficulty do you have figuring out whether bills you receive are accurate ?

(READ CATEGORIES AS NEEDED)
	(Circle One)
	No difficulty at all ......................................................	1
	A little difficulty .........................................................	2
	Moderate difficulty .....................................................	3
	Extreme difficulty .......................................................	4
	Stopped doing this because of your eyesight ..................	5
	Stopped doing this for other reasons or not interested in doing this ............................................	6

A 5. Because of your eyesight, how much difficulty do you have doing things like shaving, styling your hair, or putting on makeup ?

(READ CATEGORIES AS NEEDED)
	(Circle One)
	No difficulty at all ......................................................	1
	A little difficulty .........................................................	2
	Moderate difficulty .....................................................	3
	Extreme difficulty .......................................................	4
	Stopped doing this because of your eyesight ..................	5
	Stopped doing this for other reasons or not interested in doing this ............................................	6

SUBSCALE: DISTANCE VISION

A 6. Because of your eyesight, how much difficulty do you have recognizing people you know from across a room ?

(READ CATEGORIES AS NEEDED)
	(Circle One)
	No difficulty at all ......................................................	1
	A little difficulty .........................................................	2
	Moderate difficulty .....................................................	3
	Extreme difficulty .......................................................	4
	Stopped doing this because of your eyesight ..................	5
	Stopped doing this for other reasons or not interested in doing this ............................................	6

A 7. Because of your eyesight, how much difficulty do you have taking part in active sports or other outdoor activities that you enjoy (like golf, bowling, jogging, or walking) ?

(READ CATEGORIES AS NEEDED)
	(Circle One)
	No difficulty at all ......................................................	1
	A little difficulty .........................................................	2
	Moderate difficulty .....................................................	3
	Extreme difficulty .......................................................	4
	Stopped doing this because of your eyesight ..................	5
	Stopped doing this for other reasons or not interested in doing this ............................................	6

A 8. Because of your eyesight, how much difficulty do you have seeing and enjoying programs on TV ?

(READ CATEGORIES AS NEEDED)
	(Circle One)
	No difficulty at all ......................................................	1
	A little difficulty .........................................................	2
	Moderate difficulty .....................................................	3
	Extreme difficulty .......................................................	4
	Stopped doing this because of your eyesight ..................	5
	Stopped doing this for other reasons or not interested in doing this ............................................	6

SUBSCALE: SOCIAL FUNCTION

A 9. Because of your eyesight, how much difficulty do you have entertaining friends and family in your home ?

(READ CATEGORIES AS NEEDED)
	(Circle One)
	No difficulty at all ......................................................	1
	A little difficulty .........................................................	2
	Moderate difficulty .....................................................	3
	Extreme difficulty .......................................................	4
	Stopped doing this because of your eyesight ..................	5
	Stopped doing this for other reasons or not interested in doing this ............................................	6

SUBSCALE: DRIVING

A10. [This items,“driving in difficult conditions”, has been included as item 16a as part of the base set of 25 vision-targeted items.]

SUBSCALE: ROLE LIMITATIONS

A11. The next questions are about things you may do because of your vision. For each item, I'd like you to tell me if this is true for you all, most, some, a little, or none of the time.

SUBSCALES: WELL-BEING/DISTRESS (#A12) and DEPENDENCY (#A13)

The next questions are about how you deal with your vision. For each statement, please tell me if it is definitely true, mostly true, mostly false, or definitely false for you or you don't know.

EOF