Cataract Consultation Questionnaire

Are cloudy or blurry eyes starting to interfere with your daily life? Find out if it’s time to take the next step toward clearer vision.

Thanks for completing this! Our cataract care team will review your responses and reach out to schedule your consultation or answer any questions you may have.

In the meantime, please visit our Cataract Surgery Co-Management page to learn how we can help you navigate the cataract surgery journey with clarity and comfort.

1. Are you currently experiencing any of the following? (Check all that apply)

Blurry or cloudy visionDifficulty driving at night due to glare or halosFading or dull colorsFrequent prescription changesTrouble reading or seeing fine detailsLight sensitivityNone of the above

2. How long have you noticed these vision changes?

Less than 6 months6-12 monthsOver a yearThey came on suddenlyI haven't noticed any changes

3. Have you been told by an eye doctor that you have cataracts?

YesNoNot sure

4. Are your vision changes affecting any of the following? (Check all that apply)

DrivingReadingWatching TVWorking or using a computerEnjoying hobbies (e.g., sewing, golfing, painting)Independence or confidenceNot currently impacting my daily life

Cataract Consultation Questionnaire

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