MyCataractSurgery.com - Questionnaire

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Questionnaire

Modern Cataract surgery can be an opportunity to not only improve the clarity of your vision, but to reduce your reliance on glasses after the procedure. The purpose of MyCataractSurgery.com is to provide you with the education necessary to make an informed decision regarding your surgical options. A standard lens implant will make the distance vision relatively clear but has a limited depth of focus and therefore near and intermediate objects will be somewhat out of focus. Bifocals will be necessary to help you see near objects more clearly if you have a standard lens implant. A standard lens implant also does not correct astigmatism. Your insurance will pay for a standard lens implant, but there may be additional charges for premium lens options. To help plan for your surgery please answer the following questions.

Your Name:

Email Address:

Please rate the following statements by choosing a selection from each dropdown list:

I am bothered by blurry distance vision
I have difficulty driving at night
I have difficulty seeing road signs
Reading small print can be difficult
I require extra light to read
Bright lights worsen my vision
Words on the television are blurry
In general I would like to see better

In your own words please describe a few of your symptoms and how those
symptoms are interfering with your daily activities:

Do you have an upcoming appointment scheduled with an eye doctor for a cataract evaluation?

YES NO

Would you like a copy of this questionnaire emailed to your doctor? List doctor's email

YES NO

I am interested in being less dependant on glasses after my surgery, even if it adds additional cost to my procedure.

YES NO

I am interested in options to make near objects more clear without reading glasses, even if it adds additional cost to my procedure. I would like to read a menu without glasses.

YES NO

I am interested in advanced lens technology that may improve the clarity of my overall vision, even if it adds additional cost to my procedure. I am interested in slightly better visualization of objects in low-contrast situations such a night driving.

YES NO

I am interested in improving my ability to see clearly without glasses in the distance after my surgery. I would like my astigmatism corrected, even if it adds additional cost to my procedure.

YES NO

Do you drive at night regularly?

YES NO

What is your occupation?

How much time do you spend during the day with each of these tasks?

Shopping
Cooking
Computer work
Hobbies/crafts
Driving

Please list any unique hobbies or interests that have special visual requirements?

Check any activities that you do regularly and would like to do without glasses if possible.

	Play the piano or a musical instrument
	Work with a finely detailed hobby
	Paint pictures
	Photography
	Archery or Rifle shooting
	Read the newspaper
	Work on a computer
	Needlework, knitting, sewing
	Crossword puzzles
	Read Novels
	Golf
	Other: