Refractive Lens Exchange Self Evaluation

$Refractive Lens Exchange Self Evaluation$

First Name *

Last Name *

Phone *

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 don't mind wearing reading 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 or sewing.
Computer screens menus, price tags or headlines.
Watching TV, cooking, cleaning or indoor activities.
Driving, playing golf, seeing road signs.
Night driving, watching movies.

Refractive Lens Exchange Self Evaluation

Fill out the following questionnaire to help us assist recommending a lens option.