The Amblyopia and Strabismus Questionnaire (ASQE)

(English version, August 2005)

INSTRUCTIONS FOR USE

Instructions for the Reseacher

The Amblyopia and Strabismus Questionnaire (ASQE) was developed to measure the impact of
amblyopia and/or strabismus on the quality of life of patients. Its intended use is primarily for
research purposes and may include the assessment of the efficacy of therapeutic approaches and
the evaluation of methods of rehabilitation.
The ASQE is intended to be completed by the respondent in written and unsupervised manner,
either in an office setting or mailed to the respondents home. A few important instructions are to
be given to the respondent beforehand, see Instructions for the respondent.
The ASQE is a public document available without charge to all researchers provided that they
identify the measure as such in all publications. Users should also cite the following article:
van de Graaf ES, van der Sterre GW, Polling JR, van Kempen H, Simonsz B, Simonsz HJ.
Amblyopia & Strabismus Questionnaire: design and initial validation. Strabismus
2004;12(3):181-93.

Instructions for Scoring

Each item on the ASQE can yield a maximum (best) score of 100 points and a minimum
(worst) score of 0 points. Item answers that fall in between the two extremes are given a partial
score. For example, consider the following item with the possible response options and their
scores (points):
Double vision disturbs me in my daily activities (household, study, school,
hobbies, work).

(Circle one) Points

None of the time 1 100
A little of the time 2 75
Some of the time 3 50
Most of the time 4 25
All of the time 5 0
Not relevant, because I
6 100
never see double

Most items have 5 response options (excluding the Not relevant option), but some items have
only three response options. In those cases the possible scores are 100, 50, and 0.
If an item is unanswered or if the Not relevant option is indicated, the item yields 100 points.
The ASQE Total Score is calculated as the simple average of all item scores. The maximum
Total Score is 100 (best possible result) and the minimum score is 0 (worst possible result).

ASQE (August 2005) -i-

Instructions for the Respondent
Directions to the respondent may vary according to the purpose for which the ASQE is applied.
A basic set of instructions could look like this:

Please
Take the time to read each question carefully.
It is important for the quality of the results that you answer ALL questions.
Try to give only ONE answer to each question.
Answer each question for the situation that you are wearing your GLASSES, CONTACT
LENSES, or OPTICAL AIDS, if you regularly use them.
If a question is not clear to you, please ask the researcher for help (office version) or
write your question in the margin (mail-in version).

Thank you for your cooperation.

ASQE (August 2005) - ii -

The Amblyopia and Strabismus Questionnaire

(version August 2005)

ASQE (August 2005) -1-

SEEING WITH TWO EYES

1. I can see equally well with both eyes.

(Circle one)

Yes 1 (skip to Question 4)

No 2

2. I worry about losing my better eye.

(Circle one)

None of the time 1

......
A little of the time 2
.......
Some of the time 3
......
Most of the time 4

All of the time 5
...

3. I worry that something might get into my better eye.

(Circle one)

None of the time 1

A little of the time 2
.......
Some of the time 3
......
Most of the time 4

All of the time 5
...

4. I can estimate distances well.

(Circle one)

Yes 1
Moderate 2
No 3

ASQE (August 2005) -2-

5. I have good depth perception.

(Circle one)

Yes 1
.....
Moderate 2
No 3

6. I feel unsure or hesitant when putting something on a table.

(Circle one)

None of the time 1

.....
A little of the time 2
.......
Some of the time 3
......
Most of the time 4

All of the time 5
...

7. I miss the other persons hand when trying to shake hands.

(Circle one)

None of the time 1

......
A little of the time 2
.......
Some of the time 3
......
Most of the time 4

All of the time 5
...

8. I have difficulty parking my car.

(Circle one)

None of the time 1

......
A little of the time 2
.......
Some of the time 3
......
Most of the time 4

All of the time 5
...
Not relevant because I do not
drive a car 6

ASQE (August 2005) -3-

9. I find it difficult to put the cap on a pen or marker.

(Circle one)

None of the time 1

......
A little of the time 2
.......
Some of the time 3
......
Most of the time 4

All of the time 5
...

10. I find it difficult to put a power plug into a socket.

(Circle one)

None of the time 1

......
A little of the time 2
.......
Some of the time 3
......
Most of the time 4

All of the time 5
...

11. I have difficulties pouring drinks.

(Circle one)

None of the time 1

......
A little of the time 2
.......
Some of the time 3
......
Most of the time 4

All of the time 5
...

12. I have difficulties walking down stairs.

(Circle one)

None of the time 1

......
A little of the time 2
.......
Some of the time 3
......
Most of the time 4

All of the time 5
...

ASQE (August 2005) -4-

13. I have difficulties playing ball games.

(Circle one)

None of the time 1

......
A little of the time 2
.......
Some of the time 3
......
Most of the time 4

Most of the time 5
...
Not relevant because I do not play 6
ball games

14. I have difficulties finding my way in a shopping mall, especially when I am there for the first
time.

(Circle one)

None of the time 1

......
A little of the time 2
.......
Some of the time 3
......
Most of the time 4

All of the time 5
...
Not relevant, because I do not go 6
there

15. I have difficulties finding my way in a department store or a supermarket, especially when I
am there for the first time.

(Circle one)

None of the time 1

......
A little of the time 2
.......
Some of the time 3
......
Most of the time 4

All of the time 5
...
Not relevant, because I do not go 6
there

ASQE (August 2005) -5-

16. I have difficulties finding my way in a train station, especially when I am there for the first
time.

(Circle one)

None of the time 1

......
A little of the time 2
.......
Some of the time 3
......
Most of the time 4

All of the time 5
...
Not relevant, because I do not go
there 6

17. I see double.

(Circle one)

None of the time 1

......
A little of the time 2
.......
Some of the time 3
......
Most of the time 4

All of the time 5
...

18. Double vision disturbs me in my daily activities (household, study, school, hobbies, work).

(Circle one)

None of the time 1

......
A little of the time 2
.......
Some of the time 3
......
Most of the time 4

All of the time 5
...
Not relevant, because I never see 6
double

ASQE (August 2005) -6-

19. When I am tired, I must be very careful not to miss what I reach for.

(Circle one)

None of the time 1

......
A little of the time 2
.......
Some of the time 3
......
Most of the time 4

All of the time 5
...

20. I have to do things more slowly when I am tired because of my eyesight.

(Circle one)

None of the time 1

......
A little of the time 2
.......
Some of the time 3
......
Most of the time 4

All of the time 5
...

21. I have to squint or shut one eye in bright sunlight.

(Circle one)

None of the time 1

......
A little of the time 2
.......
Some of the time 3
......
Most of the time 4

All of the time 5
...

ASQE (August 2005) -7-

THE APPEARANCE OF MY EYES

22. I have difficulty making eye contact in a one-on-one conversation.

(Circle one)

None of the time 1

......
A little of the time 2
.......
Some of the time 3
......
Most of the time 4

All of the time 5
...

23. I have difficulty making eye contact with people in a group conversation.

(Circle one)

None of the time 1

......
A little of the time 2
.......
Some of the time 3
......
Most of the time 4

All of the time 5
...

24. My eyes are misaligned (one or both eyes cross, or turn out or turn up).

(Circle one)

None of the time 1

......
A little of the time 2
.......
Some of the time 3
......
Most of the time 4

All of the time 5
...

ASQE (August 2005) -8-

25. Because of my misaligned eyes I feel insecure.

(Circle one)

None of the time 1

......
A little of the time 2
.......
Some of the time 3
......
Most of the time 4

All of the time 5
Not relevant, because I dont have
misaligned eyes 6

26. If I did not have misaligned eyes, I would have more self-confidence.

(Circle one)

Definitely true 1
Mostly true 2
Not sure 3
Mostly false 4
Definitely false 5
Not relevant, because I dont have 6
misaligned eyes

This is the end of the questionnaire.

Thank you very much for your help.

ASQE (August 2005) -9-