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Premium Lens Self-Evaluation

Please take a minute to complete the form below, so we may better understand your vision and lifestyle needs. After completing the form, our practice coordinator will contact you to discuss the first step toward a better lifestyle with more perfect vision!

Name:

Phone:

Email:

1.

How important to you is being able to see at a distance, playing sports or driving without glasses after cataract surgery?

Very important to me; I don't wish to need glasses for distance vision.

Not important to me; I don’t mind wearing glasses to see things at a distance.

2.

How important to you is being able to read up close without glasses after cataract surgery?

Very important to me; I don't wish to wear reading glasses.

Not important to me; I don’t mind wearing glasses to see things up close.

3.

After cataract surgery, for which activity would you be most willing to wear glasses?

Reading fine print

Reading a computer screen or cookbooks

Driving a car

4.

If you had good near vision (without glasses) in most situations and for daytime driving, could you tolerate some glare and halos around lights at night?

Yes

No

5.

If you had good distance vision (without glasses) day and night and for computer work, could you tolerate wear glasses for reading fine print and small type?

Yes

No

6.

During your day-to-day activities, which of the following do you consider most important to be able to do without wearing glasses?

Reading newsprint, books, maps or sewing

Reading computer screens, menus, price tags or headlines

Watching TV, cooking, cleaning or indoor activities

Driving/seeing road signs, playing sports

Night driving, watching movies

7.

What best describes your personality?

Easy going

In the middle

Perfectionist

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