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FIGURE 8

Examiner.

Date --AMERICAN OPTOMETRIC FOUNDATION Night DRIVING APTITUDE QUESTIONNAIRE,

FORM 11-12-62 Name

Age

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

Encircle patients answers. Add numbers in parentheses to obtain his questionnaire score. 1. What part of your driving is at night? (1) None; (2) 14; (3) 12 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? (1) Yes; (2) Don't know;

(3) No. 6. Which time of day is the most difficult for you to drive? (1) Night; (2) Twi

light; (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) Some

times; (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) Usu

ally; (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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