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Catquest-9SF - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Questionnaires

Clinic No.:______ Patient ID number ____________

Catquest-9SF 2011 Questionnaire 1

Name: ______________________________________________
Street address:_________________________________________
Town and post code: ____________________________________
The aim of this questionnaire is to establish what difficulties you have in
your daily life due to impaired sight.
So that we can develop our healthcare as well as possible we are keen for
you to answer the questions in the questionnaire as honestly as you can. The questionnaire contains questions about your difficulties due to
impaired sight in connection with certain everyday tasks. If you use glasses for distance and/or close-up purposes, the questions are about what it is like when you use your best glasses.
The questions in this questionnaire (Questionnaire 1) apply to your
situation during the past 4 weeks.
We would also like to come back later with a questionnaire about 3 months after your operation (Questionnaire 2).
When you answer the questions on the next page you must try to
think only of the difficulties that your sight may be causing you. We appreciate that it may be difficult to decide just what your sight means to
you if you also have other problems such as joint pains or dizziness for example. We would still ask you to try to answer how important you think
your sight is in your ability to perform the following tasks.
When you are asked to state your difficulties, we have given three
response options. We call them very great difficulty, great difficulty and some difficulty. Different people may put things differently. Try to
see the three response options as three equal size parts of a scale ranging
from the greatest to the least difficulty caused by your sight in performing
various activities.
An example of how we envisage the scale with the three different
response options:
Greatest ______________ / ____________ / _____________least
very great difficulty great difficulty some difficulty

A. Do you find that your sight at present in some way causes you difficulty
in your everyday life?

Yes, very Yes, great Yes, some No, no Cannot
great difficulty difficulty difficulty difficulty decide
_____________________________________________________ B. Are you satisfied or dissatisfied with your sight at present?

Very Fairly Fairly Very Cannot
dissatisfied dissatisfied satisfied satisfied decide
__________________________________________________________ C. Do you have difficulty with the following activities because of your sight?

If so, to what extent? In each row place just one tick in the box which
you think best corresponds to your situation.

Yes, very Yes, great Yes, some No, no Cannot
great difficulty difficulty difficulty decide
difficulty Reading text in newspapers
Recognising the
faces of people
you meet
Seeing the prices of goods when
Seeing to walk on uneven surfaces, e.g. cobblestones
Seeing to do handicrafts, woodwork etc.
Reading subtitles on TV
Seeing to engage
in an activity/hobby
that you are
interested in Thank you very much for taking part.