Cataract Patient Lifestyle Questionnaire

If it is determined that surgery is appropriate for you, this questionnaire will help us provide the best treatment for your visual needs. It is important that you understand that many patients still need to wear glasses for some activities after surgery. Please fill this form out completely.

1. After surgery, would you be interested in seeing well without glasses in the following situations?*

   Distance vision: (driving, golf, tennis, other sports, watching television)

   Prefer no Distance glasses. I wouldn’t mind wearing Distance glasses.

   Mid-range vision: (computer, menus, price tags, cooking, board games, items on a shelf)

   Prefer no Mid-range glasses. I wouldn’t mind wearing Mid-range glasses.

   Near vision: (computer, menus, price tags, cooking, board games, items on a shelf)

   Prefer no Near glasses. I wouldn’t mind wearing Near glasses.
2. Please check the single statement that best describes you in terms of night vision:*
   a. Night vision is extremely important to me and I require the best possible quality night vision.
   b. I want to be able to drive comfortably at night, but I would tolerate some slight imperfections.
   c. Night vision is not particularly important to me.
3. If you had to wear glasses after surgery for one activity, for which activity would you be most willing to use glasses?*
   Distance Vision Mid-range Vision Near Vision
4. If you could have good Distance Vision during the day without glasses, and good Near Vision for reading without glasses, but the compromise was that you might see some halos or rings around lights at night, would you like that option?*
   Yes No
5. If you could have good Distance vision during the day and night without glasses, and good Mid-range Vision without glasses, but the compromise was that you might need glasses for reading the finest print at near, would you like that option?*
   Yes No
6. Surgery to reduce your dependence upon glasses for Distance, Mid-range and Near Vision may be partially covered by insurance if you have a cataract. Would you be interested in learning more about this option?*
   Yes No Maybe, it depends on how much is covered by insurance
7. Please select an option to describe your personality as best you can:*
   Easy Going Perfectionist

Patient Signature:*

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