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Cataract Questionnaire

Visual Functioning


Do you have difficulty, even with glasses with the following:

Reading small print such as pill bottles, newspapers, or books?
Reading traffic signs, street signs, or store signs?

Symptoms


Have you been bothered by:

Poor night vision, color vision, or double vision?
Hazy and/or blurry vision?
Seeing in dim light?
Seeing rings or halos around lights when driving at night?
Glare caused by bright lights or sunlight

Lifestyle Considerations

Do you use the computer frequently?
Do you do a lot of close, detailed work?
Do you take your glasses off to read or do fine work?
Have you had previous refractive surgery (LASIK, PRK, RK)?
Do you wear contact lenses?

Your Goals for Surgery

Please check all that apply:

Thank you for sharing this information. Our doctors utilize these answers to aid in selecting the lens that is right for you.

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