NRT Functional Vision Questionnaire

Patient Information

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Date of Birth

Phone Number

Visit Type

Primary Diagnosis (if known)

General Health & Overall Vision

NEI VFQ-25: General Health (GH) · General Vision (GV) · Ocular Pain (OP)

GH · General Health

Q1 In general, how would you rate your overall health?

Excellent Very good Good Fair Poor

GV · General Vision

Q2 At present, how would you rate your eyesight (with glasses or contact lenses, if you use them)?

Excellent Good Fair Poor Very poor Completely blind

⚬NRT mechanism: Overall VA maps to GCL+IPL complex thickness in foveal zone — primary Map NEI composite NRT readout.

GV · Worry

Q3 How much of the time do you worry about your eyesight?

None of the time A little Some of the time Most of the time All of the time

Ocular Pain · OP

Q4 How much pain or discomfort have you had in and around your eyes (burning, itching, aching)?

None Mild Moderate Severe Very severe

⚬NRT mechanism: Ocular pain signals inflammatory activity — NRT targets ocular inflammation via anti-inflammatory acupuncture and herbal pathways.

Near Vision Activities

NEI VFQ-25: Near Activities (NV) · VF-14 near tasks · LVQOL IADLs | NRT: Central macula, GCL+IPL foveal zone

NV · Newsprint

Q5How much difficulty do you have reading ordinary print in newspapers, books, or magazines?

No difficulty A little Moderate Extreme Stopped — eyesight Stopped — other

⚬NRT mechanism: Reading newsprint requires foveal cone acuity; GCL+IPL foveal thinning on Map NEI is the key predictor.

NV · Fine detail tasks

Q6How much difficulty do you have with work or hobbies requiring close vision — cooking, sewing, fixing things around the house, or using hand tools?

No difficulty A little Moderate Extreme Stopped — eyesight Stopped — other

NV · Finding items

Q7Because of your eyesight, how much difficulty do you have finding something on a crowded shelf?

No difficulty A little Moderate Extreme Stopped — eyesight Stopped — other

NV · Screen reading

Q8How much difficulty do you have reading text on a screen (phone, tablet, or computer) for 15 minutes or more?

No difficulty A little Moderate Extreme Stopped — eyesight Stopped — other

NV · Small print

Q9How much difficulty do you have reading small print — medicine labels, legal forms, or phone directories?

No difficulty A little Moderate Extreme Stopped — eyesight Stopped — other

NV · Bills & documents

Q10Because of your eyesight, how much difficulty do you have checking bills for accuracy or reading financial documents?

No difficulty A little Moderate Extreme Stopped — eyesight Stopped — other

NV · Personal grooming

Q11Because of your eyesight, how much difficulty do you have with personal care — shaving, styling hair, or applying makeup?

No difficulty A little Moderate Extreme Stopped — eyesight Stopped — other

Distance Vision Activities

NEI VFQ-25: Distance Activities (DV) · VF-14 | NRT: Outer macular ring (3–6 mm), parafoveal GCL

DV · Street signs

Q12How much difficulty do you have reading street signs or the names of stores?

No difficulty A little Moderate Extreme Stopped — eyesight Stopped — other

⚬NRT mechanism: Distance text recognition maps to extrafoveal GCL density; Map NEI outer ring (3–6 mm) sectors are primary NRT zones.

DV · Facial expressions

Q13Because of your eyesight, how much difficulty do you have seeing how people react to things you say — reading facial expressions?

No difficulty A little Moderate Extreme Stopped — eyesight Stopped — other

DV · Recognising people

Q14Because of your eyesight, how much difficulty do you have recognising people you know from across a room?

No difficulty A little Moderate Extreme Stopped — eyesight Stopped — other

DV · Television

Q15Because of your eyesight, how much difficulty do you have seeing and enjoying programs on television?

No difficulty A little Moderate Extreme Stopped — eyesight Stopped — other

DV · Sport & outdoor

Q16Because of your eyesight, how much difficulty do you have taking part in sports or outdoor activities you enjoy?

No difficulty A little Moderate Extreme Stopped — eyesight Stopped — other

DV · Steps in dim light

Q17Because of your eyesight, how much difficulty do you have going down steps, stairs, or curbs in dim light or at night?

No difficulty A little Moderate Extreme Stopped — eyesight Stopped — other

⚬NRT mechanism: Mesopic depth perception maps to rod-mediated parafoveal function; OPL/ONL thinning on Map NEI is the NRT correlate.

Peripheral Vision, Contrast & Colour

NEI VFQ-25: Peripheral (PV) · Colour (CV) | NRT: RNFL peripapillary, OPL/ONL, RPE layer integrity

PV · Side vision

Q18Because of your eyesight, how much difficulty do you have noticing objects off to the side while you are walking?

No difficulty A little Moderate Extreme Stopped — eyesight Stopped — other

⚬NRT mechanism: Peripheral field maps to peripapillary RNFL superior/inferior sectors — most sensitive NRT zones for early glaucomatous loss.

PV · Blind spots

Q19How often do you notice blank, missing, or distorted spots in your vision — areas where things seem to disappear or look wavy?

Never Rarely Sometimes Often Always

⚬NRT mechanism: Scotoma frequency localises retinal thinning to specific Map NEI sectors; paracentral scotomas map to inferior-temporal GCL.

CV · Night vision

Q20How much difficulty do you have seeing in dim light or at night — navigating dark rooms, night driving, or outdoor night walking?

No difficulty A little Moderate Extreme Stopped — eyesight Stopped — other

CV · Colour

Q21How much difficulty do you have distinguishing similar colours or seeing colour differences — matching clothes, reading coloured text?

No difficulty A little Moderate Extreme Stopped — eyesight Stopped — other

CV · Glare & photophobia

Q22How much are you bothered by glare or excessive brightness — sunlight, headlights, or digital screens?

Not at all A little Moderately Severely Cannot function

⚬NRT mechanism: Photophobia/glare — RPE dysfunction and photoreceptor stress; NRT targets oxidative RPE pathways to reduce photosensitivity. Early reduction is a positive NRT response signal.

CV · Contrast sensitivity

Q23How much difficulty do you have seeing differences between an object and its background — such as stairs vs floor, or food on a plate?

No difficulty A little Moderate Extreme Stopped — eyesight Stopped — other

Driving

NEI VFQ-25: Driving (DR) | NRT: Combined peripheral RNFL + central macular NRT

Are you currently driving a car (at least occasionally)?

Yes — I currently drive No — gave up driving because of my eyesight No — never drove or stopped for other reasons

DR · Daytime driving

Q24How much difficulty do you have driving during the daytime in familiar places?

No difficulty A little Moderate Extreme

⚬NRT mechanism: Daytime driving integrates central VA and peripheral RNFL NRT; Map NEI inferior sector thinning is highly predictive.

DR · Night driving

Q25How much difficulty do you have driving at night?

No difficulty A little Moderate Extreme Stopped — eyesight

DR · Difficult conditions

Q26How much difficulty do you have driving in difficult conditions — bad weather, rush hour, highway, or city traffic?

No difficulty A little Moderate Extreme Stopped — eyesight Stopped — other

Social Functioning, Mental Health & Daily Life

NEI VFQ-25: SF · MH · Role Limitations · Dependency | IVI-28 emotional wellbeing | Focus-QoL

SF · Social visits

Q27Because of your eyesight, how much difficulty do you have visiting people in their homes, at parties, or in restaurants?

No difficulty A little Moderate Extreme Stopped — eyesight Stopped — other

SF · Entertainment

Q28Because of your eyesight, how much difficulty do you have going out to see movies, plays, or sports events?

No difficulty A little Moderate Extreme Stopped — eyesight Stopped — other

SF · Hosting

Q29Because of your eyesight, how much difficulty do you have entertaining friends and family in your home?

No difficulty A little Moderate Extreme Stopped — eyesight Stopped — other

RL · Accomplish less

Q30Do you accomplish less than you would like because of your vision?

None of the time A little Some of the time Most of the time All of the time

RL · Time limited

Q31Are you limited in how long you can work or do other activities because of your vision?

None of the time A little Some of the time Most of the time All of the time

RL · Pain limits activity

Q32How much does pain or discomfort in or around your eyes keep you from doing what you would like to do?

None of the time A little Some of the time Most of the time All of the time

MH · Stay home

Q33I stay home most of the time because of my eyesight.

Definitely true Mostly true Not sure Mostly false Definitely false

MH · Frustration

Q34I feel frustrated a lot of the time because of my eyesight.

Definitely true Mostly true Not sure Mostly false Definitely false

MH · Less control

Q35I have much less control over what I do because of my eyesight.

Definitely true Mostly true Not sure Mostly false Definitely false

DEP · Rely on others

Q36Because of my eyesight, I have to rely too much on what other people tell me.

Definitely true Mostly true Not sure Mostly false Definitely false

DEP · Need help

Q37I need a lot of help from others because of my eyesight.

Definitely true Mostly true Not sure Mostly false Definitely false

MH · Embarrassment

Q38I worry about doing things that will embarrass myself or others because of my eyesight.

Definitely true Mostly true Not sure Mostly false Definitely false

MH · Irritability

Q39I am often irritable because of my eyesight.

Definitely true Mostly true Not sure Mostly false Definitely false

DEP · Avoid going out alone

Q40I don't go out of my home alone because of my eyesight.

Definitely true Mostly true Not sure Mostly false Definitely false

NRT-Specific Functional Outcomes

Custom Netra Institute items — please answer based on your experience over the past 2 weeks

NRT · Visual clarity

Q41Over the past 2 weeks, how would you rate the overall clarity and sharpness of your vision compared to when you started treatment?

Much worse Slightly worse No change Slightly improved Greatly improved

⚬NRT mechanism: VA improvement from GCL+IPL restoration and improved macular blood flow.

NRT · Colour vibrancy

Q42Over the past 2 weeks, how would you describe changes in colour brightness or vibrancy?

Much worse Slightly worse No change Slightly improved Clearly improved

⚬NRT mechanism: Photoreceptor IS/OS recovery enhances cone-mediated colour perception.

NRT · Photophobia

Q43Over the past 2 weeks, how has your sensitivity to bright light or glare changed?

Much more sensitive Slightly more No change Slightly reduced Greatly reduced

⚬NRT mechanism: RPE and oxidative stress reduction; acupuncture modulates autonomic photophobia responses.

NRT · Visual field

Q44Over the past 2 weeks, have you noticed any changes in your side (peripheral) vision or the size of your blind spots?

Much worse Slightly worse No change Slightly larger field Noticeably larger field

⚬NRT mechanism: Dormant retinal cell reactivation; Map NEI peripheral sector RNFL recovery is the structural correlate.

NRT · Eye fatigue

Q45Over the past 2 weeks, how much eye fatigue or strain do you experience during visual tasks?

Severe Moderate Mild Minimal None at all

⚬NRT mechanism: Improved ocular blood flow and neurotrophic support reduces cellular energy deficit causing fatigue.

NRT · Dark adaptation

Q46Over the past 2 weeks, how quickly do your eyes adjust when moving from bright to dark environments?

Very slowly Slowly About the same Somewhat faster Much faster

⚬NRT mechanism: Rod-pathway recovery; OPL/ONL layer restoration on Map NEI correlates with improved dark adaptation speed.

NRT · Reading endurance

Q47Over the past 2 weeks, how long can you read comfortably before your vision becomes blurry or fatigued?

<5 min 5–15 min 15–30 min 30–60 min >60 min

⚬NRT mechanism: Macular perfusion improvement extends photoreceptor working capacity; Map NEI central subfield thickness tracks this.

NRT · Overall improvement

Q48Overall, compared to before starting NRT, how would you describe the change in your vision?

Much worse Slightly worse No change Slightly improved Greatly improved

0 of 48 answered

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