Questionnaire – Cataract Survey

Patient Name *

Email Address

Corneal Cylinder from Biometry (CYL) *

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Steep Axis of astigmatism from Biometry (AXIS) *

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Answering the following questions can assist your doctor in formulating a custom treatment plan for you.

Which of the following answers best describes how you feel. Please choose one.

1. After cataract surgery, *

I wouldn’t mind wearing glasses all of the time
I wouldn’t mind wearing glasses sometimes
It’s important to me that I minimize my dependence on glasses

2. After cataract surgery, *

I wouldn’t mind wearing glasses for close reading only
I wouldn’t mind wearing glasses for driving or watching TV, but I don’t want to depend on glasses for close reading
I really don’t want to depend on glasses anymore

3. If I had to choose only one, after cataract surgery, it is MOST important that I can: *

See far into the distance without glasses (Driving, watching TV, tennis, golf)
Use a computer without glasses
Read a book without glasses

4. It is second most important that I can: *

See far into the distance without glasses (Driving, watching TV, tennis, golf).
Use a computer without glasses.
Read a book without glasses.
I can’t choose just one. Can I have both?

5. If there were a PERFECT lens implant, this question would not be necessary. Unfortunately, even the most advanced technology is NOT perfect. So, which is MORE important for you? *

See far into the distance without glasses (Driving, watching TV, tennis, golf).
Use a computer without glasses.
Read a book without glasses.
I must have both

6. I OFTEN drive at night *

True
False

7. So long as I could MINIMIZE my dependence on glasses, I wouldn’t mind some nighttime visual imperfections such as halos, starbursts, and/or glare around lights. *

True
False

8. While I’d like my insurance to cover the entire cost of the procedure, I understand that the technology available to improve eyesight is ahead of what health insurances covers. *

If it’ll improve my quality of vision, I’d like to utilize the best technology available, even if my insurance doesn’t cover the entire treatment.
Although there is technology to maximize the improvement in my vision, I ONLY want a treatment that my insurance will cover. I understand that my dependence on glasses will NOT be minimized.

9. Have you ever had previous surgery to decrease your need for glasses. (Such as LASIK, PRK, RK) *

10. Have you ever tried monovision (1 eye for far, and the other for near)? If so, did it work well for you? *

I tried it before, and I liked it
I tried it, and didn’t like it
I’ve never tried it