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Patient Questionnaire

To best advise you on your lens options please complete this questionnaire prior to your second visit with your doctor.

 

  1. Throughout the day you perform activities that require your eyes to focus at different distances. Please indicate which ones are MOST important to your lifestyle:

 

  • Reading up close                                               

  • Painting, reading music notes

  • Day time driving

  • Indoor activities: watching TV, cooking and cleaning

  • Sewing, knitting

  • Using a computer, tablet or smartphone

  • Night time driving

  • Outdoor sports

 

  2. Is it important to you to have a full range of vision after your surgery? This means being able to conduct everyday tasks at near, intermediate and far distances with limited need for glasses.

 

Yes No

 

  3. Following your surgery, if you need to wear glasses occasionally, for which of the following activities would that be acceptable?

 

  • Reading small print

  • Driving

  • Using a computer or cooking

  • Limited use, preferred

 

  4. How important is it for you to see well in low-light conditions?

 

Very important Fairly important but not critical Not important

 

  5. How would you describe yourself on a scale of 1-10?

 

    Easygoing     Perfectionist

 

  6. Would you be satisfied with your post surgery vision if you still had some haloes and aberrations?

 

Yes      No 

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