Table 3 National Eye Institute Visual Functioning Questionnaire – 25 (NEI-VFQ-25)

1. In general, would you say that your overall health is:

 1) Excellent  2) Very Good  3) Good  4) Fair  5) Poor

2. At the present time, would you say your eyesight using both eyes (with glasses or contact lenses, if you wear them) is:

 1) Excellent  2) Good  3) Fair  4) Very Poor  5) Completely Blind

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

 1) None of the time  2) A little of the time  3) Some of the time  4) Most of the time  5) All of the time

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

 1) None  2) Mild  3) Moderate  4) Severe  5) Very severe

PART 2 – Difficulty with Activities

The next questions are about how much difficulty you have doing a certain activity, for each question answer: 1) No difficulty at all, 2) A little difficulty, 3) Moderate difficulty, 4) Extreme difficulty, 5) Stopped doing this because of eyesight, 6) Stopped doing this for other reasons or not interested in doing this.

5. How much difficulty do you have reading ordinary print in newspapers?

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?

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

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

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

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

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

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

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

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

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

 1) Yes  2) No

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

 1) Never drove  2) Gave up

15b. IF GAVE UP DRIVING: Was that

 1) mainly because of your eyesight,  2) mainly for some other reason,  3) both your eyesight and other reasons?

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

16. How much difficulty do you have driving at night?

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?

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 1) all, 2) most, 3) some, 4) a little, or 5) none of the time.

17. Do you accomplish less than you would like because of your vision?

18. Are you limited in how long you can work or do other activities because of your vision?

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?

For each of the following statements, please tell me if it is 1) definitely true, 2) mostly true, 3) mostly false, or 4) definitely false for you or you are 5) not sure.

20. I stay home most of the time because of my eyesight.

21. I feel frustrated a lot of the time because of my eyesight.

22. I have much less control over what I do, because of my eyesight.

23. Because of my eyesight, I have to rely too much on what other people tell me.

24. I worry about doing things that will embarrass myself or others, because of my eyesight.

25. I need a lot of help from others because of my eyesight.