1. Introduction and Background questionnaire

Introduction:
This is a long questionnaire with questions about the impact of refractive error and its correction on your quality of life. Refractive error is a condition in which light entering the eye is not focused at the retina. It can be corrected by glasses, contact lenses or with laser refractive surgery. The questions were derived from the in-depth interviews with the people having refractive error. Your responses will be used to validate this questionnaire. This will enable us to develop an advanced measurement system to precisely measure quality of life with the help of only a few questions.

Instructions:
Each question is followed by all possible answers. Please choose the answer that best applies to you. Please take as much time as you need to answer each question. Your response to each of the questions is very important to us. You may skip questions that don’t apply to you (if they don’t apply to you, please select “This task is not relevant to me / don’t do the task”). 

The questionnaire has 12 sections:
1. Introduction and Background questionnaire
2. Visual symptoms
3. Ocular-comfort symptoms
4. General symptoms
5. Activity limitation
6. Mobility
7. Emotional
8. Health concerns
9. Social
10. Convenience
11. Economic
12. Coping

Please consider your refractive error and/or its correction when you answer these questions. For example, if you usually wear reading glasses or distance glasses or contact lenses please answer according to how you can see when wearing them.

If you have any queries or confusion, please contact Himal Kandel (Mobile No. +61 450 899 575; E-mail: himal.kandel@flinders.edu.au ); PhD Candidate, Discipline of Optometry, Flinders University, Adelaide, Australia.

Your participation in the study is entirely voluntary and you have the right to withdraw at any time. Declining to participate will not affect your care in any way. Completing this questionnaire typically takes about 30-40 minutes. Your consent to participate is implied by completing this questionnaire. All records containing personal information will remain confidential and no information that could lead to your identification will be released. This study has been reviewed by the Southern Adelaide Clinical Human Research Ethics Committee. If you wish to discuss the study with someone not directly involved, in particular in relation to policies, your rights as a participant, or should you wish to make a confidential complaint, you may contact the executive officer on 8204 6543 or email  SALHNofficeforresearch@sa.gov.au 
Background Questionnaire:

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Full Name

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Date of Birth

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Gender

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Country of birth

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Address

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Contact number

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E-mail address

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Do you speak a language other than English?

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What is the highest year of school you have completed?

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What is the highest level of post-school education you have achieved?

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What is your occupation?

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What is your marital status?

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In general, how would you describe your overall health?

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Eye Diagnosis

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How old were you when you first wore glasses?

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Date of last eye exam

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Do you have other eye disease/s?

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Do you have other medical conditions or diagnoses?

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Do you wear glasses?

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Do you wear contact lens?

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Contact lens type (Skip this question if you don't wear contact lens)

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Have you had a laser refractive surgery?

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If 'Yes':

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Do you have refractive correction (glasses, contact lenses or laser refractive surgery) for:

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For Habitual visual acuity and Prescription, please upload a file if relevant (pdf, doc/docx, png, jpg/jpeg, gif)

DOCX, DOC, JPG, GIF, JPEG, PDF, PNG file types only.
Choose File
No file chosen

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Habitual visual acuity: 

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Prescription for glasses

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8% of survey complete.

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