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FIGURE 8

Examiner.__

Date___.

AMERICAN OPTOMETRIC FOUNDATION NIGHT DRIVING APTITUDE QUESTIONNAIRE,

Name

N.V.P.T. Scores: 20/40 a) 20/20 b) --. ft. L.

Encircle patients answers.

naire score.

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Add numbers in parentheses to obtain his question

1. What part of your driving is at night? (1) None; (2) ; (3) 1⁄2 or more. 2. Do you find it more difficult to drive at night? (1) Yes; (2) Same; (3) No. 3. Do you prefer driving on lighted or on unlighted highways? (1) Lighted; (2) Either; (3) Unlighted.

4. Is your night driving ability as good now as it was 10 years ago? (1) No; (2) Same; (3) Better.

5. Do you think your car needs brighter headlights?

(3) No.

(1) Yes; (2) Don't know;

6. Which time of day is the most difficult for you to drive? (1) Night; (2) Twilight; (3) Same.

7. Do you avoid night driving because of your eyes? (1) Yes; (2) Sometimes; (3) No.

8. Do you prefer that someone else drive for you at night? (1) Yes; (2) Sometimes; (3) No.

9. Do you like more light for reading than you did when you were younger? (1) Yes; (2) No.

10. Do you have difficulty walking outdoors at night? (1) Yes; (2) Sometimes; (3) No.

11. Do you think you are a safe night-time driver? (1) No; (2) Average; (3) Yes. 12. Would you be afraid to ride with a driver who sees no better than you do now? (1) Yes; (2) Perhaps; (3) No.

13. Do you see streaks or rings around lights at night? (1) Yes; (2) Sometimes; (3) No.

14. Do you see double at night? (1) Frequently; (2) Sometimes; (3) Never. 15. Do you mostly drive near the center white line? (1) Yes; (2) No.

16. Do you slow down because of the glare from oncoming headlights? (1) Usually; (2) Sometimes; (3) Never.

17. Do distant objects seem blurred at night? (1) Yes; (2) Sometimes; (3) No. 18. In equal traffic conditions which is most tiring? (1) Night driving; (2) Day driving.

19. Do red taillights dazzle you at night? (1) Yes; (2) Sometimes; (3) No. 20. About how many miles do you drive in a year? (1) Less than 8,000; (2) 8,000–

15,000; (3) 15,000 or more.

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