Cataract & Refractive Lens Exchange Questionnaire

 

 

Date: _________________________                    Name: __________________________________

 

Cataract and Refractive Lens Exchange 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 will 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 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 any questions, please let us know and we will assist you with this form.

 

1.             Are you interested in seeing well 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 well 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.

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We divide vision into 5 “Zones of Vision”

Near v----------------------------------------------------------------------------------------------------w Far

 

     Zone 1                               Zone 2                                    Zone 3                   Zone 4                    Zone 5     

   (12-20 in)                                      (2-4 ft)                                    (6-20 ft)                             (20-100 ft)                (100+ ft)

 

  Newsprint                           Headlines                              Indoors                                  Day-far                   Night-far

Phone book                           Computer                                  TV                                           Driving                   Night driving

      Maps                                   Menus                                                Cooking                                   Golf                         Movies

    Sewing                       Price tags                  Cleaning                                    Road signs      Star gazing

______________________________________________________________________________

 

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

     willing to use glasses?

      ___ Reading fine print                                ___ Computer                               ___ Driving

 

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

     around lights at night, would you like that option?

     ___ Yes                                            ___ No

 

6.   If you could have good distance vision during the day and night without glasses and

      good computer-distance (Zone 2) 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.  Please place an “X” on the following scale to describe your personality as best you can:

     (- - - - - - - - - - - - - - - - - - - - - - - - - - - | - - - - - - - - - - - - - - - - - - - - - - - - - - -)

       Easy Going                                                                                                            Perfectionist

   

Please Sign Here: ____________________________________