Cataract Pre-Op Questionnaire

1. Name

2. Email

3. Phone

4. Date MMDDYYYY

5. OHIP #

6. What hobbies do you have ie Sewing Gardening Drawing Music etc

7. What sports do you play if any ie Soccer Tennis Cycling Golf etc

8. Please enter any questions or notes you have for the doctor

9. Have you ever had laser vision correction surgery in the past?
NoYes

10. Do you wear contact lenses?
NoYes

11. Do you have a pilot's license or are planning to get one?
NoYes

12. I do the majority of my tasks at:
Distance (driving, golf, tennis, other sports, watching TV)Intermediate/Mid-range (computer, menus, price tags, cooking, board games)Near (reading books, phone, tablets, e-readers, sewing, detailed handwork)

13. After surgery, I would be interested in seeing well without glasses for the following situations:
DistanceIntermediate/Mid-rangeNear

14. Please select the statement that best describes you in terms of night vision:
I want to be able to drive comfortably at night, but I would tolerate some slight imperfectionsNight vision is extremley important to me, and I require the best possible quality night visionNight vision is not particularly important to me

15. If you had to wear glasses after surgery, at which distance would you be the most willing to use glasses?
DistanceIntermediate/Mid-rangeNear

16. If you could have good distance, midrange and near vision without glasses, but the compromise was that you might see some halos, rings or starbursts around lights at night, would you like that option?:
NoYes

17. If you could have good distance, midrange and near vision without glasses, but the compromise was that you might need glasses for the finest print at near, would you like that option?:
NoYes

18. Describe your personality from 1 to 10 with 1 being Easy going and 10 being Perfectionist:
1 - Easy Going2345678910 - Perfectionist

19. Your Name (required)

20. Your Email (required)

21. Subject
Cataract Pre-Op Questionnaire

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