Cataract & Vision Questionnaire

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  • Please answer correctly the questions below before scheduling your cataract surgery. Please choose the best answer.
  • Visual Functioning
    (The following situations include wearing eyeglasses)
  • Symptoms
  • Driving
  • *This form must be filled out at each visit evaluating Cataract Surgery (New Patient, Established Patient re-evaluation, 1-week post op, etc.)
  • MM slash DD slash YYYY
  • This field is for validation purposes and should be left unchanged.

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