Cataract Pre-Op Questionnaire

Please download and fill out the fillable PDF form below. Please print the filled form and bring to your appointment.

If you prefer you can fill out the form below and submit. You will receive an email confirmation and be asked to print a physical copy to bring to your appointment.










    NoYes


    NoYes


    NoYes


    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)


    DistanceIntermediate/Mid-rangeNear


    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


    DistanceIntermediate/Mid-rangeNear


    NoYes


    NoYes


    1 - Easy Going2345678910 - Perfectionist

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