Refractive lens exchange self-evaluation
Complete the following questionnaire to help us assist in recommending a lens option.
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Refractive Lens Exchange Self Evaluation: Have you had a recent eye exam?
*
Yes
No
What provider was your most recent eye exam with?
*
Have you previously had eye surgery?
*
Yes
No
How interested are you in seeing at distance, driving or playing golf without glasses after your cataract surgery?
*
It's very important to me NOT to wear glasses for distance vision
It's not important to me, I do not mind wearing glasses
Are you interested in seeing well up close (reading) without glasses after having cataract surgery?
*
It's very important to me NOT to wear reading glasses
It's not important to me, I do not mind wearing glasses
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?
*
Reading fine print
Using a computer or cooking
Driving a car
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?
*
Yes
No
Think about the things in life you want to do the most without depending on glasses after cataract surgery. Which group is the most important?
*
Newsprint, books, reading maps, sewing
Computer screens, menus, price tags, headlines
Watching TV, cooking, cleaning, indoor activities
Driving, playing golf, seeing road signs
Night driving, watching movies
Submit
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