Activities of Daily Living Assessment

This questionnaire is required by Medicare and other insurers to document your reasons for considering cataract surgery. If you have little or no difficulty you may not need or qualify for cataract surgery at this time. It is also required that you sign and date this form.

Please accurately rate your concerns with your best vision (wear your glasses or contacts if you currently wear them). If one eye has less clear vision than the other, focus your rating on the eye that is less clear.