Name
*
First Name
Last Name
Date of Birth
*
mm/dd/yyyy
What is/was your occupation?
Please check the activities you do on a regular basis with your distance vision:
*
Daytime Driving
Sports (i.e. golf)
Nighttime Driving
Watching Movies/Going to Theater
Viewing Scenery/Photography
Please check the activities you do on a regular basis with your intermediate vision:
*
Seeing Car Dashboard
Shopping
Using Computer
Cooking
Using Tablet
Please check the activities you do on a regular basis with your near vision:
*
Reading
Playing Cards
Using Cell Phone
Applying Makeup
Needlework (sewing)
Doing Crosswords (other like games)
Are you having any difficulty with the following with your current vision?
*
Bright Daylight
Nighttime Streetlights/Headlights
Reading
How important is it to you to be free of reading glasses?
*
Not Important
1
2
3
4
Very Important
5
1 is Not Important, 5 is Very Important
How important is it to you to be free of glasses for your intermediate vision?
*
Not Important
1
2
3
4
Very Important
5
1 is Not Important, 5 is Very Important
How important is it to you to be free of glasses for your distance vision?
*
Not Important
1
2
3
4
Very Important
5
1 is Not Important, 5 is Very Important
Which of the following best describes your personality type?
*
Easygoing/flexible
Organized/Planner
Perfectionist
Would you like one of our surgical coordinators to reach out to you prior to your consultation to discuss the lens options in more detail?
*
Yes
No
Submit
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