Patient ID

Please answer correctly the questions below before scheduling your cataract surgery. Please choose the best answer.

Patient Name*

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

Symptoms

Have 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

Driving

Have 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

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Phone

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Cataract & Vision Questionnaire