| ENTRY SPECIFICATION |
{"name": "LVVFQ",
were using the device or technique."
{"id": "c5330", "text": "9. UNSCORED - Patient not interested in activity", "quickKey": 9}
]},
{"id": "q8781", "type": "ChoiceQuestion", "required": true, "inline": false,
"text": "7. Find something on a crowded shelf",
"intro": "<strong>For each of the following <u>items</u> select one response to indicate the difficulty
level.</strong><br/><br/>These questions relate to reading and near vision
activities. Remember if you use a low vision device, adaptive device, or an
adaptive technique to assist with the activity then please respond as though you
were using the device or technique.",
"columns": 1,
},
"choices":[
{"id": "c5331", "text": "1. NOT difficult", "quickKey": 1},
{"id": "c5332", "text": "2. SLIGHTLY/MODERATELY difficult", "quickKey": 2},
{"id": "c5333", "text": "3. EXTREMELY difficult", "quickKey": 3},
{"id": "c5334", "text": "4. IMPOSSIBLE", "quickKey": 4},
{"id": "c5330", "text": "9. UNSCORED - Patient not interested in activity", "quickKey": 9}
]},
{"id": "q8778", "type": "ChoiceQuestion", "required": true, "inline": false,
"text": "8. Identify medicine",
"intro": "<strong>For each of the following <u>items</u> select one response to indicate the difficulty
{"id": "q8768", "type": "ChoiceQuestion", "required": true, "inline": false,
level.</strong><br/><br/>These questions relate to reading and near vision
activities. Remember if you use a low vision device, adaptive device, or an
adaptive technique to assist with the activity then please respond as though you
were using the device or technique.",
"columns": 1,
"choices":[
{"id": "c5331", "text": "1. NOT difficult", "quickKey": 1},
{"id": "c5332", "text": "2. SLIGHTLY/MODERATELY difficult", "quickKey": 2},
{"id": "c5333", "text": "3. EXTREMELY difficult", "quickKey": 3},
{"id": "c5334", "text": "4. IMPOSSIBLE", "quickKey": 4},
"text": "1. Read newspaper or magazine articles",
{"id": "c5330", "text": "9. UNSCORED - Patient not interested in activity", "quickKey": 9}
]},
{"id": "q8779", "type": "ChoiceQuestion", "required": true, "inline": false,
"text": "9. Tell time",
"intro": "<strong>For each of the following <u>items</u> select one response to indicate the difficulty
level.</strong><br/><br/>These questions relate to reading and near vision
activities. Remember if you use a low vision device, adaptive device, or an
adaptive technique to assist with the activity then please respond as though you
were using the device or technique.",
"columns": 1,
"intro": "<strong>For each of the following <u>items</u> select one response to indicate the difficulty
"choices":[
{"id": "c5331", "text": "1. NOT difficult", "quickKey": 1},
{"id": "c5332", "text": "2. SLIGHTLY/MODERATELY difficult", "quickKey": 2},
{"id": "c5333", "text": "3. EXTREMELY difficult", "quickKey": 3},
{"id": "c5334", "text": "4. IMPOSSIBLE", "quickKey": 4},
{"id": "c5330", "text": "9. UNSCORED - Patient not interested in activity", "quickKey": 9}
]},
{"id": "i2530", "type": "IntroText",
"text": "These questions relate to distance visual activities. Remember if you use a low
vision device, adaptive device, or an adaptive technique to assist with the
level.</strong><br/><br/>These questions relate to reading and near vision
activity then please respond as though you were using the device or technique."
},
{"id": "q8786", "type": "ChoiceQuestion", "required": true, "inline": false,
"text": "10. Read street signs",
"intro": "These questions relate to distance visual activities. Remember if you use a low
vision device, adaptive device, or an adaptive technique to assist with the
activity then please respond as though you were using the device or technique.",
"columns": 1,
"choices":[
{"id": "c5331", "text": "1. NOT difficult", "quickKey": 1},
activities. Remember if you use a low vision device, adaptive device, or an
{"id": "c5332", "text": "2. SLIGHTLY/MODERATELY difficult", "quickKey": 2},
{"id": "c5333", "text": "3. EXTREMELY difficult", "quickKey": 3},
{"id": "c5334", "text": "4. IMPOSSIBLE", "quickKey": 4},
{"id": "c5330", "text": "9. UNSCORED - Patient not interested in activity", "quickKey": 9}
]},
{"id": "q8783", "type": "ChoiceQuestion", "required": true, "inline": false,
"text": "11. Read print on TV",
"intro": "These questions relate to distance visual activities. Remember if you use a low
vision device, adaptive device, or an adaptive technique to assist with the
activity then please respond as though you were using the device or technique.",
adaptive technique to assist with the activity then please respond as though you
"columns": 1,
"choices":[
{"id": "c5331", "text": "1. NOT difficult", "quickKey": 1},
{"id": "c5332", "text": "2. SLIGHTLY/MODERATELY difficult", "quickKey": 2},
{"id": "c5333", "text": "3. EXTREMELY difficult", "quickKey": 3},
{"id": "c5334", "text": "4. IMPOSSIBLE", "quickKey": 4},
{"id": "c5330", "text": "9. UNSCORED - Patient not interested in activity", "quickKey": 9}
]},
{"id": "q8782", "type": "ChoiceQuestion", "required": true, "inline": false,
"text": "12. Watch TV",
were using the device or technique.",
"intro": "These questions relate to distance visual activities. Remember if you use a low
vision device, adaptive device, or an adaptive technique to assist with the
activity then please respond as though you were using the device or technique.",
"columns": 1,
"choices":[
{"id": "c5331", "text": "1. NOT difficult", "quickKey": 1},
{"id": "c5332", "text": "2. SLIGHTLY/MODERATELY difficult", "quickKey": 2},
{"id": "c5333", "text": "3. EXTREMELY difficult", "quickKey": 3},
{"id": "c5334", "text": "4. IMPOSSIBLE", "quickKey": 4},
{"id": "c5330", "text": "9. UNSCORED - Patient not interested in activity", "quickKey": 9}
"columns": 1,
]},
{"id": "i2531", "type": "IntroText",
"text": "The following questions are about other daily living activities. Remember if you
use a low vision device, adaptive device, or an adaptive technique to assist
with the activity then please respond as though you were using the device or
technique."
},
{"id": "q8772", "type": "ChoiceQuestion", "required": true, "inline": false,
"text": "13. Handle finances",
"intro": "The following questions are about other daily living activities. Remember if you
"restartDays": 2,
"choices":[
use a low vision device, adaptive device, or an adaptive technique to assist
with the activity then please respond as though you were using the device or
technique.",
"columns": 1,
"choices":[
{"id": "c5331", "text": "1. NOT difficult", "quickKey": 1},
{"id": "c5332", "text": "2. SLIGHTLY/MODERATELY difficult", "quickKey": 2},
{"id": "c5333", "text": "3. EXTREMELY difficult", "quickKey": 3},
{"id": "c5334", "text": "4. IMPOSSIBLE", "quickKey": 4},
{"id": "c5330", "text": "9. UNSCORED - Patient not interested in activity", "quickKey": 9}
{"id": "c5331", "text": "1. NOT difficult", "quickKey": 1},
]},
{"id": "q8773", "type": "ChoiceQuestion", "required": true, "inline": false,
"text": "14. Take a message",
"intro": "The following questions are about other daily living activities. Remember if you
use a low vision device, adaptive device, or an adaptive technique to assist
with the activity then please respond as though you were using the device or
technique.",
"columns": 1,
"choices":[
{"id": "c5331", "text": "1. NOT difficult", "quickKey": 1},
{"id": "c5332", "text": "2. SLIGHTLY/MODERATELY difficult", "quickKey": 2},
{"id": "c5332", "text": "2. SLIGHTLY/MODERATELY difficult", "quickKey": 2},
{"id": "c5333", "text": "3. EXTREMELY difficult", "quickKey": 3},
{"id": "c5334", "text": "4. IMPOSSIBLE", "quickKey": 4},
{"id": "c5330", "text": "9. UNSCORED - Patient not interested in activity", "quickKey": 9}
]},
{"id": "q8775", "type": "ChoiceQuestion", "required": true, "inline": false,
"text": "15. Prepare meals",
"intro": "The following questions are about other daily living activities. Remember if you
use a low vision device, adaptive device, or an adaptive technique to assist
with the activity then please respond as though you were using the device or
{"id": "c5333", "text": "3. EXTREMELY difficult", "quickKey": 3},
technique.",
"columns": 1,
"choices":[
{"id": "c5331", "text": "1. NOT difficult", "quickKey": 1},
{"id": "c5332", "text": "2. SLIGHTLY/MODERATELY difficult", "quickKey": 2},
{"id": "c5333", "text": "3. EXTREMELY difficult", "quickKey": 3},
{"id": "c5334", "text": "4. IMPOSSIBLE", "quickKey": 4},
{"id": "c5330", "text": "9. UNSCORED - Patient not interested in activity", "quickKey": 9}
]},
{"id": "q8780", "type": "ChoiceQuestion", "required": true, "inline": false,
{"id": "c5334", "text": "4. IMPOSSIBLE", "quickKey": 4},
"text": "16. Use appliance dials",
"intro": "The following questions are about other daily living activities. Remember if you
use a low vision device, adaptive device, or an adaptive technique to assist
with the activity then please respond as though you were using the device or
technique.",
"columns": 1,
"choices":[
{"id": "c5331", "text": "1. NOT difficult", "quickKey": 1},
{"id": "c5332", "text": "2. SLIGHTLY/MODERATELY difficult", "quickKey": 2},
{"id": "c5333", "text": "3. EXTREMELY difficult", "quickKey": 3},
{"id": "c5330", "text": "9. UNSCORED - Patient not interested in activity", "quickKey": 9}
{"id": "c5334", "text": "4. IMPOSSIBLE", "quickKey": 4},
{"id": "c5330", "text": "9. UNSCORED - Patient not interested in activity", "quickKey": 9}
]},
{"id": "q8777", "type": "ChoiceQuestion", "required": true, "inline": false,
"text": "17. Groom yourself",
"intro": "The following questions are about other daily living activities. Remember if you
use a low vision device, adaptive device, or an adaptive technique to assist
with the activity then please respond as though you were using the device or
technique.",
"columns": 1,
]},
"choices":[
{"id": "c5331", "text": "1. NOT difficult", "quickKey": 1},
{"id": "c5332", "text": "2. SLIGHTLY/MODERATELY difficult", "quickKey": 2},
{"id": "c5333", "text": "3. EXTREMELY difficult", "quickKey": 3},
{"id": "c5334", "text": "4. IMPOSSIBLE", "quickKey": 4},
{"id": "c5330", "text": "9. UNSCORED - Patient not interested in activity", "quickKey": 9}
]},
{"id": "q8774", "type": "ChoiceQuestion", "required": true, "inline": false,
"text": "18. Eat and drink neatly",
"intro": "The following questions are about other daily living activities. Remember if you
{"id": "q8769", "type": "ChoiceQuestion", "required": true, "inline": false,
use a low vision device, adaptive device, or an adaptive technique to assist
with the activity then please respond as though you were using the device or
technique.",
"columns": 1,
"choices":[
{"id": "c5331", "text": "1. NOT difficult", "quickKey": 1},
{"id": "c5332", "text": "2. SLIGHTLY/MODERATELY difficult", "quickKey": 2},
{"id": "c5333", "text": "3. EXTREMELY difficult", "quickKey": 3},
{"id": "c5334", "text": "4. IMPOSSIBLE", "quickKey": 4},
{"id": "c5330", "text": "9. UNSCORED - Patient not interested in activity", "quickKey": 9}
"text": "2. Read mail",
]},
{"id": "i2532", "type": "IntroText",
"text": "The last set of questions deal with issues of mobility. Remember if you use a low
vision device, adaptive device, or an adaptive technique to assist with the
activity then please respond as though you were using the device or technique."
},
{"id": "q8785", "type": "ChoiceQuestion", "required": true, "inline": false,
"text": "19. Get around outdoors in places you know",
"intro": "The last set of questions deal with issues of mobility. Remember if you use a low
vision device, adaptive device, or an adaptive technique to assist with the
"intro": "<strong>For each of the following <u>items</u> select one response to indicate the difficulty
activity then please respond as though you were using the device or technique.",
"columns": 1,
"choices":[
{"id": "c5331", "text": "1. NOT difficult", "quickKey": 1},
{"id": "c5332", "text": "2. SLIGHTLY/MODERATELY difficult", "quickKey": 2},
{"id": "c5333", "text": "3. EXTREMELY difficult", "quickKey": 3},
{"id": "c5334", "text": "4. IMPOSSIBLE", "quickKey": 4},
{"id": "c5330", "text": "9. UNSCORED - Patient not interested in activity", "quickKey": 9}
]},
{"id": "q8787", "type": "ChoiceQuestion", "required": true, "inline": false,
"printTitle": "Low Vision Visual Functioning Questionnaire",
level.</strong><br/><br/>These questions relate to reading and near vision
"text": "20. Adjust to bright light",
"intro": "The last set of questions deal with issues of mobility. Remember if you use a low
vision device, adaptive device, or an adaptive technique to assist with the
activity then please respond as though you were using the device or technique.",
"columns": 1,
"choices":[
{"id": "c5331", "text": "1. NOT difficult", "quickKey": 1},
{"id": "c5332", "text": "2. SLIGHTLY/MODERATELY difficult", "quickKey": 2},
{"id": "c5333", "text": "3. EXTREMELY difficult", "quickKey": 3},
{"id": "c5334", "text": "4. IMPOSSIBLE", "quickKey": 4},
activities. Remember if you use a low vision device, adaptive device, or an
{"id": "c5330", "text": "9. UNSCORED - Patient not interested in activity", "quickKey": 9}
]}]
}
adaptive technique to assist with the activity then please respond as though you
were using the device or technique.",
"columns": 1,
"choices":[
{"id": "c5331", "text": "1. NOT difficult", "quickKey": 1},
{"id": "c5332", "text": "2. SLIGHTLY/MODERATELY difficult", "quickKey": 2},
{"id": "c5333", "text": "3. EXTREMELY difficult", "quickKey": 3},
{"id": "c5334", "text": "4. IMPOSSIBLE", "quickKey": 4},
"content":[
{"id": "c5330", "text": "9. UNSCORED - Patient not interested in activity", "quickKey": 9}
]},
{"id": "q8776", "type": "ChoiceQuestion", "required": true, "inline": false,
"text": "3. Read menus",
"intro": "<strong>For each of the following <u>items</u> select one response to indicate the difficulty
level.</strong><br/><br/>These questions relate to reading and near vision
activities. Remember if you use a low vision device, adaptive device, or an
adaptive technique to assist with the activity then please respond as though you
were using the device or technique.",
"columns": 1,
{"id": "i2472", "type": "IntroText",
"choices":[
{"id": "c5331", "text": "1. NOT difficult", "quickKey": 1},
{"id": "c5332", "text": "2. SLIGHTLY/MODERATELY difficult", "quickKey": 2},
{"id": "c5333", "text": "3. EXTREMELY difficult", "quickKey": 3},
{"id": "c5334", "text": "4. IMPOSSIBLE", "quickKey": 4},
{"id": "c5330", "text": "9. UNSCORED - Patient not interested in activity", "quickKey": 9}
]},
{"id": "q8770", "type": "ChoiceQuestion", "required": true, "inline": false,
"text": "4. Read small print on package labels",
"intro": "<strong>For each of the following <u>items</u> select one response to indicate the difficulty
"text": "<strong>For each of the following <u>items</u> select one response to indicate the difficulty
level.</strong><br/><br/>These questions relate to reading and near vision
activities. Remember if you use a low vision device, adaptive device, or an
adaptive technique to assist with the activity then please respond as though you
were using the device or technique.",
"columns": 1,
"choices":[
{"id": "c5331", "text": "1. NOT difficult", "quickKey": 1},
{"id": "c5332", "text": "2. SLIGHTLY/MODERATELY difficult", "quickKey": 2},
{"id": "c5333", "text": "3. EXTREMELY difficult", "quickKey": 3},
{"id": "c5334", "text": "4. IMPOSSIBLE", "quickKey": 4},
level.</strong><br/><br/>These questions relate to reading and near vision
{"id": "c5330", "text": "9. UNSCORED - Patient not interested in activity", "quickKey": 9}
]},
{"id": "q8771", "type": "ChoiceQuestion", "required": true, "inline": false,
"text": "5. Keep your place while reading",
"intro": "<strong>For each of the following <u>items</u> select one response to indicate the difficulty
level.</strong><br/><br/>These questions relate to reading and near vision
activities. Remember if you use a low vision device, adaptive device, or an
adaptive technique to assist with the activity then please respond as though you
were using the device or technique.",
"columns": 1,
activities. Remember if you use a low vision device, adaptive device, or an
"choices":[
{"id": "c5331", "text": "1. NOT difficult", "quickKey": 1},
{"id": "c5332", "text": "2. SLIGHTLY/MODERATELY difficult", "quickKey": 2},
{"id": "c5333", "text": "3. EXTREMELY difficult", "quickKey": 3},
{"id": "c5334", "text": "4. IMPOSSIBLE", "quickKey": 4},
{"id": "c5330", "text": "9. UNSCORED - Patient not interested in activity", "quickKey": 9}
]},
{"id": "q8784", "type": "ChoiceQuestion", "required": true, "inline": false,
"text": "6. See photos",
"intro": "<strong>For each of the following <u>items</u> select one response to indicate the difficulty
adaptive technique to assist with the activity then please respond as though you
level.</strong><br/><br/>These questions relate to reading and near vision
activities. Remember if you use a low vision device, adaptive device, or an
adaptive technique to assist with the activity then please respond as though you
were using the device or technique.",
"columns": 1,
"choices":[
{"id": "c5331", "text": "1. NOT difficult", "quickKey": 1},
{"id": "c5332", "text": "2. SLIGHTLY/MODERATELY difficult", "quickKey": 2},
{"id": "c5333", "text": "3. EXTREMELY difficult", "quickKey": 3},
{"id": "c5334", "text": "4. IMPOSSIBLE", "quickKey": 4},
|
