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Cataract Questionnaire

 

Cataract Functional Impairment Questionnaire


 Patient Name: _____________________________________

                                                                                                     Eye:  Right  | Left 

 

Visual Functional Status (circle responses)

1) Do you have difficulty seeing street signs or to drive?                              Yes      No | Yes      No                          
(curbs, freeway exits, traffic lights, halos/glare around lights)


2) Do you have difficulty seeing TV or movies?                                           Yes      No | Yes      No

(faces, numbers, or printing)

3) Do you have difficulty reading small print with good light, blinking
and proper glasses?                                                                                        Yes      No | Yes      No
(books, newspaper, telephone book, medicine labels, instructions)


4) Do you have difficulty with performing handiwork?                                Yes      No | Yes      No

(sewing, knitting, crocheting, embroidery or other fine tasks)

5) Do you have difficulty with personal correspondences?                          Yes      No | Yes      No
(writing checks, reading bills, filling out forms)

6) Do you have difficulty with leisure activities?                                          Yes      No | Yes      No

(playing card games, bingo, dominoes, or sport activities such as
bowling, hunting, golf, tennis, other ___________________)         

7) Do you have visual difficulty with navigation around the house?          Yes      No | Yes      No

(cooking, ironing, general household upkeep, climbing steps or curbs,
dialing the telephone, telling time on a watch, using public transportation)

8) Are you able to see and recognize faces of people?                                 Yes      No | Yes      No
(in church, grocery store, clubs, and other daily activities?)

9) Are you able to care for yourself with your present vision?                    Yes      No | Yes      No

10) Do you live alone and wish to remain independent?                             Yes      No | Yes      No

Do you have any of the following VISUAL SYMPTOMS?

1) Double or distorted vision?                                                                        Yes      No | Yes      No
2) Glares, halos, rings around lights?                                                             Yes      No | Yes      No

3) Difficulty with color perception?                                                               Yes      No | Yes      No
4) Difficulty with depth perception?                                                              Yes      No | Yes      No
5) Worsening of vision- blurred vision?                                                        Yes      No | Yes      No


Cataract surgery can almost always be safely postponed until you feel you need better vision.

If stronger glasses won’t improve you 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


Signature:_______________________________________ Date:___________________

c modified by Ohio Valley Eye Institute

 

Evansville Main Office

1001 Walnut St.,
Evansville, IN 47713
866.295.2020

Evansville East

6540 Logan Dr.
Evansville, IN 47715
812.421.2020

Terre Haute 812.478.2020

Henderson 270.831.2010