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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