Lifestyle Questions

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 - daytimeDriving - nighttimeGolfing/other sportsViewing scenery/taking photographsOther
Intermediate Vision

Seeing car dashboardShoppingUsing computerPlaying cardsUsing tabletOther
Near Vision

Reading books/newspapersSewing/needlepointingDoing crossword puzzlesApplying makeupUsing cell phoneOther
Which of the following activities do you have difficulty with?

ReadingDriving at nightUsing the computer or electronic devicesWatching TVCrafts/HobbiesRecognizing faces across the roomOther
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)

1

2

3

4

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)

1

2

3

4

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)

1

2

3

4

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 knowledgeableSomewhat knowledgeableKnowledgeable
Which of the following best describes your personality type?

EasygoingFlexibleOrganized/PlannerPerfectionist
Should be Empty:

Tell Us About You

Please select the following activities you do on a regular basis:

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).