Cataract Assessment and Surgery Intake Form
Use this form to share cataract symptoms, eye-specific concerns, and surgery intake details so the clinic can prepare for your assessment and next steps. Do not include sensitive identification or financial information.
Patient Information
Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Cataract Assessment
Eye Being Assessed
*
Left eye
Right eye
Both eyes
Primary Vision Concerns
*
Blurry vision
Glare or halos
Trouble driving at night
Difficulty reading
Faded colors
Frequent prescription changes
Other
Symptom Severity
*
1
2
3
4
5
Impact on Daily Activities
*
Not at all affected
1
2
3
4
5
6
7
8
9
Severely affected
10
1 is Not at all affected, 10 is Severely affected
Surgery Intake and Scheduling
Have you had prior eye surgery?
*
Yes
No
Preferred surgery or consultation date and time
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Preparation notes, allergies, or medications the clinic should know about
Submit
Should be Empty: