Cataract questionaire

Cataract Questionnaire
The term “cataract” refers to a cloudy lens within the eye. When a cataract is removed, an
artificial lens is placed inside the eye to take the place of the human lens that has become the
cataract. Occasionally, clear lenses that have not yet developed cataracts are also removed to
reduce or eliminate the need for glasses or contacts. This questionnaire wil assist us in providing
the treatment best suited for your visual needs, if it is determined that surgery is appropriate for
you. It is important that you understand that many patients stil need to wear glasses for some
activities after surgery. Please fill this form out completely and Dr. Stefano wil review it. We wil
gladly assist you with this form, should you need any help.
1. Are you interested in seeing wel at distance without glasses after surgery?
____ Prefer no distance glasses.
____ Not important to me. I wouldn’t mind wearing distance glasses.

2. Are you interested in seeing wel at near without glasses after surgery?
____ Prefer no reading glasses.
____ Not important to me. I wouldn’t mind wearing reading glasses.

3. Zones of Vision:
We divide vision into 5 “Zones of Vision”
(12-20 in)
(2-4 ft.)
(6-20 ft.)
(20-100 ft.)
(100 ft.+)

Which group of “Zones of Vision” is the most important group to you? Please choose only one of
the following three options of Group A, B or C:
___Group A: Zones 1, 2 and 3.
___Group B: Zones 2, 3 and 4.
___Group C: Zones 3, 4 and 5.

4. If you had to wear glasses after surgery for one activity, for which activity would you be most
wil ing to use glasses?
___Reading fine print.
___Computer.
___Driving.

(Questionnaire continues on back)
5. If you could have good distance vision during the day without glasses, and good near vision
for reading without glasses, but the compromise was that you might see some halos and
starbursts
around lights at night, would you like that option?
____ Yes
____ No
6. If you could have good distance vision during the day without glasses, and good reading
vision without glasses, but the compromise was that you might need glasses for reading the finest
print at near, would you like that option?
____ Yes
____ No

7. If you could have good distance vision during the day without glasses, and good reading
vision without glasses, but the compromise was that you stil might need glasses for seeing the
computer, would you like that option?
____ Yes
____ No
8. Have you ever tried mono-vision contact lenses?
____ Yes
____ No

9. Are you currently taking aspirin, Plavix, Coumadin?
____ Yes
____ No

10. Have ever taken Flomax, Uroxatral, Cardura, or Hytrin?
____ Yes
____ No
11. Please place an “X” on the fol owing scale to describe your personality as best you can:
[----------------------------------------------------------------I---------------------------------------------------------------]
Easy going


Date________________________


Name_____________________________________

Please Sign Here _________________________________

Source: http://www.seeclear.com/pdf/cataract-questionaire.pdf

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