VISATAX
The following questionnaire is about your sight and your feelingsabout your sight, without taking into account your possible imbalance and clumsiness.
At each question, you are invited to choose the answer which suits the best with your condition.Take as much time as necessary to answer at each question.
Remember that if you wear glasses or contact lenses,answer as if you were wearing them.
Try to provide a single answer at each question. If you do not know which answer to choose, selectthe one that illustrates the best to your condition. Comments are welcome.
Thank you for your collaboration!
I/ Are you disturbed byyoursightduring your travels in the street, by car or by train?
❑No
❑YesIfYES:
❑ Slightly
❑Fairly
❑Extremely
II/ In the street,are you able to see and readbillboards?
❑Yes
❑NoIf NO, is it because of:
❑Double vision
❑Photophobia
❑Oscillopsias
❑You cannot specify
III/ In the street, are you able to see and read the patches of street name?
❑Yes
❑NoIf NO, is itbecause of:
❑Double vision
❑Photophobia
❑Motion of the visual world
❑You cannot specify
IV/ Because of your sight, do you have any difficulties to look at and readTVprograms?
❑No
❑YesIf YES, is it because of:
❑Double vision
❑Photophobia
❑Motion of the visual world
❑You cannot specify
V/ If you watch a foreign moviesub-titled in French, are youable to read subtitles?
❑Yes
❑NoIf NO, is it because of:
❑Double vision
❑Photophobia
❑Motion of the visual world
❑Because it is written too small
❑Because it goes too fast
❑You cannot specify
VI/ When using a computer, do you have any difficulties to read what is written on the screen?
❑No
❑YesIfYES,is it because of:
❑Double vision
❑Photophobia
❑Motion of the visual world
❑You cannot specify
VII/ Is your computer equipped with a software of swelling or with speech synthesis?
❑Yes
❑No
VIII/Because of your sight, do you haveany difficulties to recognize known persons in a room?
❑No
❑YesIf YES:
❑Slightly
❑Fairly
❑Extremely
IX/ Do you read?
❑Yes
❑NoIf NO, is it because of:
❑Double vision
❑Photophobia
❑Motion of the visual world moves
❑Small size of the characters
❑Lack of energy
❑You cannot specify
X/ If you read, do you encounter any difficulties in readingnotes, administrative documents, newspapers or common printed matters?
❑No
❑YesifYES, is it becauseof:
❑Double vision
❑Photophobia
❑Motion of the visual world moves
❑Small size of the characters
❑You cannot specify
XI/ Do you do crossword puzzles or tangled words or similar games?
❑Yes
❑No
XII/ If you practice this kind of leisure, do you encounter any difficulties?
❑No
❑YesIf YES,is it becauseof:
❑Double vision
❑Photophobia
❑ Motion of the visual world
❑You cannot specify
XIII/ Because of your sight,do you think that there are tasks which you cannot realize?
❑Yes
❑No
If VISATAXhas not covered all the visual problems which you feel, please describe them: