West Georgia Eye Care Premium IOL Evaluation
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First Name
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Last Name
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Contact Number
Email address
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Please select todays date
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How important is it to you following cataract surgery to see at a distance i.e. driving, playing golf, etc.?
It’s very important to me to not wear glasses for distance vision.
It’s not that important to me to wear glasses.
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How important is it to you following cataract surgery to see well up close i.e. reading?
It’s very important to me to not wear glasses for reading.
It’s not very important to me to wear reading glasses to see up close.
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If you had to wear glasses following cataract surgery, which activities would be acceptable to you for wearing glasses?
(Near) Reading, sewing
(Intermediate) Using a computer, watching TV, cooking,
(Far) Driving, see road signs, golf
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Would you be able to accept any glare or halos around lights at night if, without glasses, you had good distance vision during the day and good near vision?
Yes
No
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Would you be willing to wear reading glasses if you could have good distance vision day and night along with good intermediate vision i.e. computer distance?
Yes
No
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Do you have to sit up front in meetings or worship services in order to undersand the speaker?
Yes
No
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Please describe your temperament or personality.
Calm, easy going, accommodating
Business like, reasonable, moderate
Anxious, perfectionist, detailed
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Indicates Response Required