VF-14-Questionnaire
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Today's Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Type a question
Rows
none
a little
Moderate
Great Deal
Unable to do
reading small print, such as medicine bottle labels, a telephone book, or food labels
reading a newspaper or a book
reading a large print book or large print newspaper or numbers on a telephone
Recognizing people when they are close to you
Seeing steps, stairs or curbs
Reading traffic signs, street signs or store signs
Doing fine handwork like sewing, knitting, crocheting, carpentry
Writing checks or filling out forms
Playing games such as bingo, dominos, card games, or mahjong
Taking part in sports like bowling, handball, tennis, golf
Cooking
Watching television
Driving during the day
Driving at night
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