Cataract & Vision Questionnaire Patient IDPlease answer correctly the questions below before scheduling your cataract surgery. Please choose the best answer.Patient Name* First Last Office where you are being treated*DoverSeafordMillvilleEye Being Evaluated*RTLTBothVisual Functioning (The following situations include wearing eyeglasses)Are you struggling to read small print, such as labels on medicine bottles, telephone books or food labels?*YesNoN/AAre you struggling to read the newspaper or books?*YesNoN/AAre you struggling to read large-print book, or a large-print newspaper, or large numbers on a telephone?*YesNoN/AAre you struggling to recognize people when they are close to you?*YesNoN/AAre you having trouble seeing steps, stairs or curbs?*YesNoN/AAre you having trouble reading traffic signs, street signs or store signs?*YesNoN/AAre you having trouble doing fine handwork like sewing, threading needles, doing crafts, crocheting, word puzzles or carpentry?*YesNoN/AAre you having trouble writing checks or filling out forms?*YesNoN/AAre you having a hard time playing cards with your friends or playing board games such as bingo and domino?*YesNoN/AIs it more difficult playing sports like bowling, handball, tennis, or golf, or participating in activities that you enjoy?*YesNoN/AAre you having trouble cooking?*YesNoN/AAre you having trouble seeing the television or seeing the lettering across the television?*YesNoN/ACan you see the computer screen?*YesNoN/ASymptomsHave you been bothered by poor night vision?*YesNoN/AHave you been bothered by seeing halos around lights?*YesNoN/AHave you been bothered by glare caused by headlights or bright sunlight?*YesNoN/AHave you been bothered by hazy and/or blurry vision?*YesNoN/AHave you been bothered by seeing well in poor or dim light?*YesNoN/AHave you been bothered by poor color vision?*YesNoN/AHave you been bothered by double vision?*YesNoN/ADrivingHave you ever driven a car?*Yes (continue)No (stop)Do you currently drive a car?*Yes (continue)No (stop)How much difficulty do you have driving during the day because of your vision?*No difficultyA little difficultyA moderate amount of difficultyA great deal of difficultyHow much difficulty do you have driving at night because of your vision?*No difficultyA little difficultyA moderate amount of difficultyA great deal of difficultyCataract surgery can almost always be safely postponed until you feel need better vision. If stronger glasses won’t improve your vision any more, and if the only to help you see better is cataract surgery, do you feel your vision problem is bad enough to consider cataract surgery now?*YesNo*This form must be filled out at each visit evaluating Cataract Surgery (New Patient, Established Patient re-evaluation, 1-week post op, etc.)Consent* I agree to the privacy policy. By checking this box and filling my name below, I hereby certify that the above statements are true and correct to the best of my knowledge.*Signature (Full Name)*Date Date Format: MM slash DD slash YYYY CAPTCHAPhoneThis field is for validation purposes and should be left unchanged. Copyright © [year] Eye Specialists of Delaware. All Rights Reserved.