Visual Quality Scale

Name

Date

Directions

For each of the following questions, please select the number for the response which best represents you answer. Please provide an answer for all 9 questions listed.

In general, would you say that you have problems with your eyes.

How would you rate the clearness of your vision (with glasses or contact lenses when doing certain tasks, for example, watching television, movies, driving, reading, writing or sewing)?

How often have you had episodes of blurred vision, and/or double vision during the past 4 weeks?

To what extent do problems with your eyes limit your ability to do certain tasks or the amount of time that you need to do them ( for example, because you become tired, lose concentration or are not able to see well enough to complete the tasks)?

How often do you lose your place, reread the same line, or skip lines when you are reading or copying (for example, when going back to the beginning of the next line you find yourself on the line just read)?

To what extent does bright light and/or dim light affect your ability to do certain tasks?

How often have your eyes hurt, watered, burned, itched or become red or swollen in the past 4 weeks?

How often have you had headaches during the past 4 weeks?

To what extent are you embarrassed when others notice your eye turn in, out, move independently, or that you are unable to do certain tasks because of your eyes? (If this does not apply to you chose 6.)

Signature

Average

Total