Cataract Self Test

First Name

Last Name

Phone Number

1. How interested are you in seeing at a distance, driving or playing golf without glasses after your cataract surgery?

2. My distance vision is

3. Are you interested in seeing well up close (reading) without glasses after your cataract surgery?

4. My close vision is

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?

6. I have halos and glare at night?

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?

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?