Name * Email * Phone Number * How did you hear about us? * Friend Referring Doctor Google Search Facebook Instagram Newspaper / Magazine Radio TV Other How did you hear about us? Additional Comments How interested are you in seeing at a 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 your cataract surgery? It's very important to me NOT to wear reading glasses. It's not important to me. I do not mind wearing reading glasses to see things up close. 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 If you could have good distance vision day and night, and good vision for computer work, without glasses, would you be willing to wear glasses for reading fine print and small type? Yes No Scale 1 2 3 4 5 6 7 8 9 10 In our daily lives there are different things we do that require us to SEE at different distances. We have grouped some of these vision activities into 5 lifestyle zones. Think about the things in life you want to do the most without depending on glasses Newsprint, books, reading maps or sewing. Computer screens, menus, price tages or headlines. Watching TV, cooking, cleaning or indoor activities. Driving, playing golf, seeing road signs. Night Driving, watching movies. Consider your personality. Based on the options scale below how would you rank your personality? Easy Going In the middle Perfectionist If you are human, leave this field blank.