CATARACT SURGERYCANDIDACY TEST
Nielsen Eye Center
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Are you having trouble with your vision?
Yes
No
Have you had any previous eye operations? (Refractive surgery / LASIK, or Lasers)
Yes
No
Do you currently wear anything to correct your vision? (check all that apply)
Reading glasses only
Glasses (Distance, Bi-focals, Tri-focals or progressive)
Contact lenses
No Correction
Have you been told you have cataracts and require surgery?
Yes
No
Think about your vision when looking in the distance (driving, playing golf). How important is it for you to do these tasks without glasses after surgery?
I am very interested in not wearing glasses for distance vision
I am moderately interested in not wearing glasses for distance vision
I don't mind wearing glasses, so it is not important to me
Think about your near vision (reading, cell phone). How important is it for you to do these tasks without glasses after cataract surgery?
I am very interested in not wearing reading glasses
I am moderately interested in not wearing reading glasses
I don't mind wearing glasses, so it is not importantto me
How important is clear night vision for you after cataract surgery?
Very important
Moderately important
No important
Below are 4 zones of vision. Consider things in life you want to do without dependence on glasses, which group is most important to your lifestyle? (check all that apply )
Far (T.V., night driving, road signs, golf)
Intermediate (computer, cooking, grocery shelf items, iPad)
Near (newsprint, phone book, mops, sewing)
Very Near (tying a fly, embroidery, knitting, setting jewerly stones)
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