Cataract Evaluation Appointment

Patient Name*

We are very excited that you have chosen to see Dr. Salib at Orange County Eye Institute and our staff for your cataract evaluation! We look forward to seeing you soon. If for any reason you need to reschedule, please inform our office at least (3) business days prior to your visit. If you wear contact lenses, please discontinue their use for at least three weeks prior to your appointment.

Enclosed is some general information about our practice and the advanced intraocular lenses that we offer our cataract patients. Our goal is to provide you with as much information as you need, so you can make an informed decision about the vision you would like to have for the rest of your life. We encourage you to review this material and to please fill out these attached questionnaires prior to your visit so that we may answer any questions that you might have.

During surgery, Dr. Salib uses the latest in laser-assisted cataract surgery for the most precise and modern method of performing cataract surgery. In fact, he was one of the earliest adopters of this groundbreaking technology, making him also one of the most experienced in its use.

As a cataract patient, you have several options for your lens replacement. We are proud to offer the newest in multifocal technology, the Panoptix Trifocal Intraocular lens (IOL), which has given patients the ability to have a clear vision for the full range of distances--far, near and intermediate. We are also excited to offer Vivity IOL, an extended depth of focus lens to allow for a more broad range of vision. If you have astigmatism, a Toric IOL would help sharpen your vision. So many choices—but no need to worry—Dr. Salib will give you his expert opinion and guidance in regards to the surgery and IOL choice.

Lastly, you will receive a call from us to remind you about your appointment. In the interim, please contact me should you need any information prior to your appointment. Thank you for trusting your eyes to Dr. Salib at Orange County Eye Institute.

Best Regards,

Surgical Coordinator

Lifestyle Questionnaire

Eye Being Evaluated :*

Date of Birth*

Visual Functioning:

Do you still have difficulty, even with glasses, with the following activities?

Reading a newspaper or book?

Reading a large-print book, or large-print newspaper, or large numbers on a telephone?

Recognizing people when they are close to you?

Seeing steps, stairs or curbs?

Reading traffic signs, street signs, or store signs?

Writing checks or filling out forms?

Playing games such as BINGO, dominos, or card games?

Taking part in sports like bowling, handball, tennis or golf?

Watching television?

Getting around in your home?


Have You been bothered by:

Poor Night vision?

Seeing rings or hales around lights?

Glare caused by headlights or bright sunlight?

Seeing well in poor or dim light?

Poor color vision?

Double vision?


How much difficulty do you have driving at night because of your vision?

When did you stop driving?

Cataract Surgery is elective and can almost always be safely postponed until you feel you need better vision. If stronger glasses will not improve your vision anymore, and if the only way to help you see better is cataract surgery, would you consider having cataract surgery now?

Patient Signature*



Quality of Vision Checklist

At the Orange County Eye Institute, we strive to provide the best quality of care and customized vision solutions for our patients. This checklist will assist us in providing the treatment best suited for your visual needs and lifestyle. It Is Important for you to be aware that some or all patients still may need to wear glasses for some activities after surgery.

Patient Name

What is your occupation/former occupation?

What are your favorite hobbies?

If you work, what are some of your daily work-related tasks?

How much time per day do you spend on the computer?

Does your work or livelihood require excessive night-time driving?

Which of the following activities would you be most interested doing well without glasses

Other activities you would enjoy without glasses

Other What sporting or recreational activities do you currently engage in?

If you could have good Distance, Intermediate, and Near Vision with a lens that reduces your need for glasses, but the compromise would be that you might see some halos, rings, or starbursts around lights mostly at night, would you like that option?

Please tell us about any vision concerns that are not addressed above

How do you feel about your life right now, on a scale of 1 to 10?

How satisfied are you with your medical treatment?

Select on the following scale to describe your personality as best you can:

You will need to have an EKG and a physical before your Cataract surgery. Please indicate the provider you will want to see so we can send them the paper work on your behalf.

Patient Signature*