YAG Capsulotomy Questionnaire 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 Do you have difficulty, even with glasses, with the following activities?Seeing clearly in bright lights (e.g., bright sunlight)* Yes No N/A Seeing to drive at dusk or in the dark?* Yes No N/A Recognizing people when they are close to you?* Yes No N/A Reading traffic signs, street signs, or store signs?* Yes No N/A Doing fine handwork like sewing, knitting, crocheting or carpentry?* Yes No N/A Watching television?* 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 YAG laser capsulotomy 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 YAG laser surgery, do you feel your vision problem is bad enough to consider laser surgery now?* Yes No *This form must be completed prior to each YAG CapConsent* 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 CAPTCHANameThis field is for validation purposes and should be left unchanged. Copyright © [year] Eye Specialists of Delaware. All Rights Reserved.
