Cataract & Vision Questionnaire HiddenPatient ID Please 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* Dover Seaford Millville Eye Being Evaluated* RT LT Both Visual 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?* Yes No N/A Are you struggling to read the newspaper or books?* Yes No N/A Are you struggling to read large-print book, or a large-print newspaper, or large numbers on a telephone?* Yes No N/A Are you struggling to recognize people when they are close to you?* Yes No N/A Are you having trouble seeing steps, stairs or curbs?* Yes No N/A Are you having trouble reading traffic signs, street signs or store signs?* Yes No N/A Are you having trouble doing fine handwork like sewing, threading needles, doing crafts, crocheting, word puzzles or carpentry?* Yes No N/A Are you having trouble writing checks or filling out forms?* Yes No N/A Are you having a hard time playing cards with your friends or playing board games such as bingo and domino?* Yes No N/A Is it more difficult playing sports like bowling, handball, tennis, or golf, or participating in activities that you enjoy?* Yes No N/A Are you having trouble cooking?* Yes No N/A Are you having trouble seeing the television or seeing the lettering across the television?* Yes No N/A Can you see the computer screen?* Yes No N/A SymptomsHave you been bothered by poor night vision?* Yes No N/A Have you been bothered by seeing halos around lights?* Yes No N/A Have you been bothered by glare caused by headlights or bright sunlight?* Yes No N/A Have you been bothered by hazy and/or blurry vision?* Yes No N/A Have you been bothered by seeing well in poor or dim light?* Yes No N/A Have you been bothered by poor color vision?* Yes No N/A Have you been bothered by double vision?* Yes No N/A DrivingHave 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 difficulty A little difficulty A moderate amount of difficulty A great deal of difficulty How much difficulty do you have driving at night because of your vision?* No difficulty A little difficulty A moderate amount of difficulty A great deal of difficulty Cataract 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?* Yes No *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 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.
