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. If it is determined that surgery is
appropriate for you, this questionnaire will help us provide the best treatment
for your visual needs. It is important that you understand that many patients
still need to wear glasses for some activities after surgery. Please fill this
form out completely and give it to the doctor. If you have questions, please
let us know and we will assist you with this form.
1. After surgery, would you be interested in seeing well without glasses in the following
Distance vision (driving, golf, tennis, other sports, watching TV)
___Prefer no Distance
glasses. ___ I would not mind wearing Distance glasses.
Mid-range vision. (computer, menus, price tags, cooking, board
games, items on a shelf)
no Mid-range glasses. ___ I would not mind wearing Mid-range
Near vision (reading
books, newspapers, magazines, detailed handwork)
___Prefer no Near
glasses. ___ I would not mind wearing Near glasses.
2. Please check the single
statement that best describes you in terms of night vision:
___ a. Night vision is extremely important to me, and I require the best
possible quality night vision.
___ b. I want to be able to drive comfortably at night, but I would
tolerate some slight imperfections.
___ c. Night vision is not
particularly important to me.
3. If you had to wear
glasses after surgery for one activity, for which activity would you be most willing to use glasses?
____Distance Vision ____Mid-range Vision ____Near Vision.
4. 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 or rings
around lights at night, would that option be acceptable to you? ____Yes ____No
5. If you could have good Distance
vision during the day and night without glasses, and good Mid-range Vision without glasses, but
the compromise was that you might need glasses for reading the finest print at
near, would that option be acceptable to you?
6. Surgery to reduce or eliminate your dependence upon glasses for Distance, Mid-range and Near Vision may
be partially covered by insurance if you have a cataract that is covered by insurance.
Would you be interested in learning more about this option?
____Yes ____No ____Maybe,
it depends on how much is covered by insurance.
7. Please place an “X” on the following scale to describe your
personality as best you can:
8. Which is your dominant
Please Sign Here__________________________________