Cataract & Vision Questionnaire Patient IDPlease answer correctly the questions below before scheduling your cataract surgery. Please choose the best answer.Patient ID* First Last Visual FunctioningDo you have difficulty, even with glasses, with the following activities?Reading small print, such as labels on medicine bottles, telephone books or food labels?*YesNoReading a newspaper or a book?*YesNoRecognizing people when they are close to you?*YesNoReading a large-print book, or a large-print newspaper, or large numbers on a telephone?*YesNoSeeing steps, stairs or curbs?*YesNoReading traffic signs, street signs or store signs?*YesNoDoing fine handwork like sewing, knitting, crocheting, or carpentry?*YesNoWriting checks or filling out forms?*YesNoPlaying games such as bingo, dominos, or card games?*YesNoTaking part in sports like bowling, handball, tennis, or golf?*YesNoCooking?*YesNoWatching television?*YesNoSymptomsPoor night vision?*YesNoSeeing rings or halos around lights?*YesNoGlare caused by headlights or bright sunlight?*YesNoHazy and/or blurry vision?*YesNoSeeing well in poor or dim light?*YesNoPoor color vision?*YesNoDouble vision?*YesNoDrivingHave you ever driven a car?*YESNODo you currently drive a car?*YesNoHow 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 difficultyWhen did you stop driving?*Less than 6 months ago6-12 months agoMore than 1 year agoCataract surgery can almost always be safely postponed until you feel you need better vision. If stronger glasses won't improve your vision any more, and if the only way to help you see better is cataract surgery, do you feel your vision problem is bad enough to consider cataract surgery now?*YesNoDate Date Format: MM slash DD slash YYYY CAPTCHAPhoneThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle Ajax powered Gravity Forms. Copyright © [year] Eye Specialists of Delaware. All Rights Reserved.
