Vision/Lifestyle Survey

In addition to gaining clearer vision after cataract surgery, patients today have more of a choice in their visual outcome. This is achieved by replacing the clouded natural lens of the eye with a new clear lens (IOL) that has prescription power specifically measured for the individual patient. Some lenses best correct at distance, some at near, some at both distance and near, and some for astigmatism. For these reasons, no one lens is right for every patient. Also, some lenses are an additional cost for the patient. Please help us to better understand your visual goals by answering the questions below

First Name*

Legal Name

Last Name*

Date of Appointment

Location

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What is your current or former occupation?

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What are your favorite hobbies or interests?

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Have you ever worn contacts to correct one eye for distance and one eye for near?

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If yes, was it succesful?

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Do you feel that dry conditions affect your vision?

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How do you feel about wearing glasses?

Please check all that apply

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Would you be willing to pay an out-of-pocket expense for a lens that compensates for astigmatism, if needed?

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Would you be willing to pay an out-of-pocket expense for a lens that decreases your dependence on glasses for near/reading and far distances, if you are a candidate?

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