Pre-Surgical Cataract Patient Questionnaire Page 4
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1
2
3
4SYMPTOMS
YES
NO
(continued)
5. Seeing well in poor or dim light?
6. Poor color vision?
7. Double vision?
DRIVING
1. Have you ever driven a car?
YES (continue)
NO (stop)
2. Do you currently drive a car?
YES (continue)
NO (stop)
3. How much difficulty do you have driving during the day because of your vision?
No difficulty
A moderate amount of difficulty
A little difficulty
A great deal of difficulty
4. How much difficulty do you have driving at night because of your vision?
No difficulty
A moderate amount of difficulty
A little difficulty
A great deal of difficulty
5. When did you stop driving?
Less than 6 months ago
6-12 months ago
More than 1 year ago
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?
YES
NO
Patient Signature _______________________________
Date __________________
Witness
______________________________
Date __________________
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