Cataract Self-Test

Age Group

Under 18 18 - 45 46 - 60 60+

Do You Normally Wear:

Reading Glasses Single Vision Glasses Bifocals or Trifolcals Contact Lenses

Describe your vision with your glasses or contact lenses – pleases check all of the areas you have difficulty with

Driving

Daytime: bothered by sun’s glare Nightime: Haloes at Night Nightime: Poor Vision Dusk: Difficult discerning details

Reading

Newspaper Mail Books Medicine Bottle Need plenty of light to read

Household

Difficulty reading recipes or labels Difficulty walking – difficult to see pavement Difficulty shaving/bathing Difficulty with household responsibilities Difficulty caring for family Difficulty shopping

Hobbies

Sewing Stamp Collecting Gardening Coin Collecting Sports Watching TV Other

Do you have any of these conditions?

Macular Degeneration Glaucoma Double Vision Dry Eye

Have you ever had an eye injury or eye surgery?

Yes No If Yes, please explain below:

When choosing a surgeon which of these is important to you?

Experience Safety Outcomes Compassionate Care

How important is improving your vision so you don’t need contact lenses or glasses?

I don't care I want the best possible

What medical and/or vision insurance do you have?

Questions/Comments?