Vision-Related Quality of Life Questionnaire Form
Please complete this questionnaire to help us understand your vision-related quality of life.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Age
*
Gender
*
Please Select
Male
Female
Other
Type of Vision Issue
*
Please Select
Myopia
Hyperopia
Astigmatism
Presbyopia
Other
Difficulty in Seeing at Night
*
Not at all Difficult
1
2
3
4
Extremely Difficult
5
1 is Not at all Difficult, 5 is Extremely Difficult
Difficulty in Reading Small Print
*
Not Difficult
1
2
3
4
Very Difficult
5
1 is Not Difficult, 5 is Very Difficult
Frequency of Using Visual Aids (glasses, contacts)
*
Rarely
1
2
3
4
Always
5
1 is Rarely, 5 is Always
Impact of Vision Problems on Daily Activities
*
No Impact
1
2
3
4
Severe Impact
5
1 is No Impact, 5 is Severe Impact
Additional Comments or Concerns
Submit
Should be Empty: