Visual Functioning
Pre-Surgical Cataract Patient Questionnaire
Patient Full Name
*
First Name
Last Name
What is your occupation?
What is your occupation?
Visual Functioning
Do you have difficulty, even with glasses, with the following activities? Select YES or NO.
YES
NO
1. RIGHT EYE: Reading small print, such as labelson medicine
1. LEFT EYE: Reading small print, such as labels on medicine
2. RIGHT EYE: Bottles, telephone books, or food labels?
2. LEFT EYE: Bottles, telephone books, or food labels?
3.RIGHT EYE :Reading a newspaper or book?
3.LEFT EYE :Reading a newspaper or book?
4.RIGHT EYE: Reading a large-print book, large-printnewspapers, or large numbers on a telephone?
4.LEFT EYE: Reading a large-print book, large-printnewspapers, or large numbers on a telephone?
5. RIGHT EYE: Recognizing people when they are close to you?
5. LEFT EYE EYE: Recognizing people when they are close to you?
6. RIGHT EYE: Seeing steps, stairs ,or curbs?
6. LEFT EYE: Seeing steps, stairs ,or curbs?
7. RIGHT EYE: Reading traffic signs, street signs, or store signs?
7. LEFT EYE: Reading traffic signs, street signs, or store signs?
8. RIGHT EYE: Doing fine handworks like sewing, knitting, crocheting, or carpentry?
8. LEFT EYE: Doing fine handworks like sewing, knitting, crocheting, or carpentry?
9. RIGHT EYE: Writing checks or filling out forms?
9. LEFT EYE: Writing checks or filling out forms?
10. RIGHT EYE: Playing games such as bingo, dominos ,or card games?
10. LEFT EYE: Playing games such as bingo, dominos ,or card games?
11. RIGHT EYE: Taking part in sports like bowling, handball, tennis, or golf?
11. LEFT EYE: Taking part in sports like bowling, handball, tennis, or golf?
12. RIGHT EYE: Cooking?
12. LEFT EYE: Cooking?
13.RIGHT EYE: Watching television?
13.LEFT EYE: Watching television?
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Symptoms
Have you been bothered by: SELECT YES or NO.
YES
NO
1. RIGHT EYE: Poor Night Vision?
1. LEFT EYE: Poor Night Vision?
2. RIGHT EYE: Seeing rings or halos around light?
2. LEFT EYE: Seeing rings or halos around light?
3. RIGHT EYE: Glare caused by headlights or bright sunlight?
3. LEFT EYE: Glare caused by headlights or bright sunlight?
4. RIGHT EYE: Hazy and/or blurry vision?
4. LEFT EYE: Hazy and/or blurry vision?
5. RIGHT EYE: Seeing well in poor or dim light?
5. LEFT EYE: Seeing well in poor or dim light?
6. RIGHT EYE: Poor Color Vision?
6. LEFT EYE: Poor Color Vision?
7. RIGHT EYE: Double Vision?
7. LEFT EYE: Double Vision?
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Driving
1. Have you ever driven a car?
*
Yes (Continue)
No (STOP Answering Questions & Proceed to Question Number 6)
2. Do you currently drive a car?
Yes (Continue)
No (STOP Answering Questions & Proceed to Question Number 5)
3. RIGHT EYE :How much difficulty do you drive during the day because of your vision?
No difficulty
A little difficulty
A moderate amount difficulty
A great deal of difficult
3. LEFT EYE :How much difficulty do you drive during the day because of your vision?
No difficulty
A little difficulty
A moderate amount difficulty
A great deal of difficult
4. RIGHT EYE :How much difficulty do you have driving at night because of your vision?
No difficulty
A little difficulty
A moderate amount difficulty
A great deal of difficult
4. LEFT EYE :How much difficulty do you have driving at night because of your vision?
No difficulty
A little difficulty
A moderate amount difficulty
A great deal of difficult
5. When did you stop driving?
Less than 6 months
6-12 months ago
More than 1 year ago
6. Cataract surgery can almost always be safely postponed until you feel you need better vision. If stronger glasses won’t improve your vision anymore, 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
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Patient Signature
Date
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Month
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Day
Year
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