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?
(curbs, freeway exits, traffic lights, halos/glare around lights)
2) Do you have difficulty seeing TV or movies? (faces, numbers, or printing)
3) Do you have difficulty reading small print with good light, blinking
and proper glasses?
(books, newspaper, telephone book, medicine labels, instructions)
4) Do you have difficulty with performing handiwork?
(sewing, knitting, crocheting, embroidery or other fine tasks)
5) Do you have difficulty with personal correspondences?
(writing checks, reading bills, filling out forms)
6) Do you have difficulty with leisure activities? (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? (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? (in church, grocery store, clubs, and other daily activities?)
9) Are you able to care for yourself with your present vision?
10) Do you live alone and wish to remain independent?
Do you have any of the following VISUAL SYMPTOMS?
1) Double or distorted vision?
2) Glares, halos, rings around lights?
3) Difficulty with color perception?
4) Difficulty with depth perception?
5) Worsening of vision- blurred vision?
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?
Signature:_______________________ Date:____________