Name
Email
Phone
1. How interested are you in seeing at a distance, driving or playing golf without glasses after your cataract surgery?
Select
It's very important to me NOT to wear glasses for distance vision.
It's not important to me. I do not mind wearing glasses.
2. My distance vision is
Select
Good
OK
Poor
3. Are you interested in seeing well up close (reading) without glasses after your cataract surgery?
Select
It's very important to me NOT to wear reading glasses.
It's not important to me. I do not mind wearing reading glasses to see things up close.
4. My close vision is
Select
Good
OK
Poor
5. If you had to wear glasses after your vision treatment for one of the following activities, which one would you most be willing to wear glasses for?
Select
Reading fine print
Using a computer or cooking
Driving a car
6. I have halos and glare at night?
Select
Yes
No
7. If you could have good vision for driving during the day without glasses, and good near vision without glasses in most situations, would you be able to tolerate some halos and glare around lights at night?
Select
Yes
No
8. If you could have good distance vision day and night, and good vision for computer work, without glasses, would you be willing to wear glasses for reading fine print and small type?
Select
Yes
No