Tell Us About You
Understanding your lifestyle and the activities you enjoy can help us recommend the kind of cataract surgery that will provide you with clearer vision and less dependence on glasses.
Name
*
What is (or was) your occupation?
Please select the following activities you do on a regular basis:
Distance Vision
Driving - daytime
Driving - nighttime
Golfing/other sports
Viewing scenery/taking photographs
Other
Intermediate Vision
Seeing car dashboard
Shopping
Using computer
Playing cards
Using tablet
Other
Near Vision
Reading books/newspapers
Sewing/needlepointing
Doing crossword puzzles
Applying makeup
Using cell phone
Other
Which of the following activities do you have difficulty with?
Reading
Driving at night
Using the computer or electronic devices
Watching TV
Crafts/Hobbies
Recognizing faces across the room
Other
On a scale from 1 to 5, rate each of the below based on how you feel about glasses (1 I want to wear glasses – 5 I don’t want to wear glasses).
Correction of near vision (e.g., reading, use of phone)
I want to wear glasses
1
2
3
4
I don't want to wear glasses
5
1 is I want to wear glasses, 5 is I don't want to wear glasses
Correction of intermediate vision (e.g., using a tablet/computer)
I want to wear glasses
1
2
3
4
I don't want to wear glasses
5
1 is I want to wear glasses, 5 is I don't want to wear glasses
Correction of distance vision (e.g., driving, watching television)
I want to wear glasses
1
2
3
4
I don't want to wear glasses
5
1 is I want to wear glasses, 5 is I don't want to wear glasses
Your doctor will discuss the advantages and disadvantages of the various options for cataract surgery. Please indicate how knowledgeable you are about your cataract surgery options:
Not knowledgeable
Somewhat knowledgeable
Knowledgeable
Which of the following best describes your personality type?
Easygoing
Flexible
Organized/Planner
Perfectionist
Submit
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