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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
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