Vision Preferences Checklist

The term "cataract" refers to a cloudy lens within the eye. When a cataract is removed, a lens implant is placed inside the eye to replace the cloudy human lens. Occasionally, clear lenses that have not yet developed cataracts are also removed to reduce or eliminate the need for glasses or contacts. If it is determined that surgery is appropriate for you, this questionaire will help us provide the best treatment for your visual needs. Please fill this form out completely and return it to us.

Patient Name
Home Phone
Email
If surgery is recommended for you, would you be interested in seeing well without glasses in the following situations?
	Distance Vision: driving, golf, tennis, other sports, watching TV
	Mid-Range Vision: computer, menus, price tags, cooking, board games, items on a grocery shelf
	Near Vision: reading books, newspapers, magazines, detailed handwork
Please check the single statement that best describes you in terms of night vision:
	Night vision is extremely important to me, and I require the best possible quality night vision.
	I want to be able to drive comfortably at night, but I would tolerate some slight imperfections
	Night vision is not particularly important to me
How many hours per day do you spend:
	On the computer
	Reading books, newspapers, typed documents or small print
	Driving
If you could have good Distance Vision during the day without glasses, and good Near Vision for reading without glasses, but the compromise was that you might see some halos or rings around lights at night, would that be OK with you?
	Yes
	No
If you could have good Distance Vision during the day and night without glasses, and good Mid-Range Vision without glasses, but the compromise was that you might need glasses for reading very small print at near, would you like that option?
	Yes
	No
Please list up to three favorite hobbies:

Lens Options