Pre-surgical Cataract Patient Questionnaire

VISUAL FUNCTIONING

Do you have difficulty, even with glasses, with the following activities?

Reading small print, such as labels on medicine bottles, telephone books, food labels, or newspapers?*

YesNo

Reading a large-print book, or large-print newspaper, or large numbers on a telephone?*

YesNo

Recognizing people when they are close to you?*

YesNo

Seeing steps, stairs or curbs?*

YesNo

Reading traffic signs, street signs, or store signs?*

YesNo

Doing fine handwork like sewing, knitting, crocheting, or carpentry?*

YesNo

Watching television?*

YesNo

SYMPTOMS

Have you been bothered by:

Seeing well in poor or dim light?*

YesNo

Poor color vision?*

YesNo

DRIVING

Do you currently drive a car?

YesNo

How much difficulty do you have driving during the day because of your vision?

No difficultyA little difficultyA moderate amount of difficultyA great deal of difficulty

How much difficulty do you have driving at night because of your vision?

No difficultyA little difficultyA moderate amount of difficultyA great deal of difficulty

Cataract 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?

YESNO

Name*

Signature

Date