• VISUAL FUNCTIONING

    Do you have difficulty, even with glasses, with the following activities?

  • Reading small print, such as labels on medicine bottles, telephone books, food labels, or newspapers?*
  • Reading a large-print book, or large-print newspaper, or large numbers on a telephone?*
  • Recognizing people when they are close to you?*
  • Seeing steps, stairs or curbs?*
  • Reading traffic signs, street signs, or store signs?*
  • Doing fine handwork like sewing, knitting, crocheting, or carpentry?*
  • Watching television?*

  • SYMPTOMS

    Have you been bothered by:

  • Seeing well in poor or dim light?*
  • Poor color vision?*

  • DRIVING

  • Do you currently drive a car?
  • How much difficulty do you have driving during the day because of your vision?
  • How much difficulty do you have driving at night because of your vision?
  • 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?
  • Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Should be Empty: