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Quality of Life Questionnaire

Please use the following response scale:

0: Never; 1: Seldom; 2: Occasionally; 3: Frequently; 4: Always

The above Quality of Life Questionnaire has been thoroughly researched and validated as a screening tool for vision problems, which changes with treatment.

20-24 points - Suspect.

25 or more points - Refer for care.

Subtotals: 4 x ___; 3 x ___; 2 x ___; 1 x ___