Quality of Life Questionnaire- online form

Quality of Life Questionnaire
Patient Name*

First NameLast Name
Form completed by:*
Please indicate your relation to the patient: (Mom, Dad, Guardian, etc.)
Date*

MonthDayYear
Date
Patient Age (years):
If you are responding on behalf of a child, we suggest parents estimate their own opinions FIRST.

We understand that some of these questions are Not Applicable to all individuals. Based on your observations, please provide your best estimate, or select "Never (0)".
If your child is too young to read the questions, please interview the child separately, after submitting your form.
A response is required for each of the questions below.

(1 of 3) Please indicate the frequency for each of the following questions. ** If you are unsure, please estimate, or enter Never (0).*

Rows	Never (0)	Seldom (1)	Occasionally (2)	Frequently (3)	Always (4)
1. I have blurred vision when looking at near objects.
2. I have double vision. (Seeing two objects rather than one.)
3. I have headaches with near work.
4. Words run together when I read.
5. My eyes burn, itch and water.
6. I fall asleep when I read.
7. I see worse at the end of the day.
8. I skip or repeat lines when reading.
9. I feel dizzy or sick to my stomach with near work.
10. I tilt my head or cover an eye when reading.

(2 of 3) Please indicate the frequency for each of the following questions. ** If you are unsure, please estimate, or enter Never (0).*

Rows	Never (0)	Seldom (1)	Occasionally (2)	Frequently (3)	Always (4)
11. I have difficulty copying from the chalkboard.
12. I avoid reading and near work.
13. I leave out small words when reading.
14. I write uphill or downhill (My handwriting tends to slant up or down).
15. Columns of numbers appear misaligned.
16. I don’t understand what I read.
17. I am poor in sports.
18. I hold my reading very close.
19. I have trouble keeping attention on reading.
20. I have difficulty completing assignments on time.

(3 of 3) Please indicate the frequency for each of the following questions. ** If you are unsure, please estimate, or enter Never (0).*

Rows	Never (0)	Seldom (1)	Occasionally (2)	Frequently (3)	Always (4)
21. I often say, “I can’t” before trying.
22. I avoid sports and games.
23. I have poor hand/eye coordination
24. I do not judge distance accurately.
25. I am clumsy.
26. I do not use my time well.
27. I do not do well in figuring out change (money).
28. I lose papers and belongings.
29. I have trouble with car/motion sickness.
30. I am forgetful with a poor memory.

Quality of Life Questionnaire