Eye Being Evaluated
Right
Left
Both
Visual Functioning
Do you have difficulty, even with glasses, with the following activities
1. Reading small print, such as labels on medicine?
Yes
No
2. Reading a newspaper or book?
Yes
No
3. Reading a large-print book or newspaper, or large numbers on a telephone?
Yes
No
4. Recognizing people when they are close to you?
Yes
No
5. Seeing steps, stairs, or curbs?
Yes
No
6. Reading traffic signs, street signs, or store signs?
Yes
No
7. Doing fine handwork like sewing, knitting, or carpentry?
Yes
No
8. Writing checks or filling out forms?
Yes
No
9. Playing games such as bingo, dominos, or card games?
Yes
No
10. Taking part in sports like bowling, tennis, or golf
Yes
No
11. Cooking?
Yes
No
12. Watching television?
Yes
No
SYMPTOMS
Have you been bothered by:
1. Poor night vision?
Yes
No
2. Seeing rings or halos around lights?
Yes
No
3. Glare caused by headlights or bright sunlight?
Yes
No
4. Hazy and/or blurry vision?
Yes
No
5. Unable to see well in poor or dim light?
Yes
No
6. Poor color vision?
Yes
No
7. Double vision, or ghost images around objects or letters?
Yes
No
DRIVING
1. Do you currently drive a car?
Yes (answer 2-3 below)
No (answer 4 below)
2. How difficult is it to drive during the day due to your vision?
Not difficult
A little difficult
Moderately difficult
Very difficult
3. How difficult is it to drive at night due to your vision?
Not difficult
A little difficult
Moderately difficult
Very difficult
4. Did you stop driving due to your vision?
Yes
No
Cataract surgery can often 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?
Yes
No
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