Cataract Self Evaluation Name* Phone* Email* After cataract surgery, would you be interested in seeing well without glasses for distance vision? Examples: Driving, Watching TV, Golf, Tennis, Other sports I prefer no glasses for distance vision. I would not mind wearing glasses for distance vision. After cataract surgery, would you be interested in seeing well without glasses for mid-range vision? Examples: Computer, Menus, Price Tags, Cooking, Board Games, Items on a shelf I prefer no glasses for mid-range vision. I would not mind wearing glasses for mid-range vision. After cataract surgery, would you be interested in seeing well without glasses for near vision? Examples: Reading Books, Smartphones, Tablets, E-Readers, Sewing, Detailed handwork I prefer no glasses for near vision. I would not mind wearing glasses for near vision. Please check the single statement that best describes you in terms of night vision. Night vision is extremely important to me. 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. If you had to wear glasses after surgery for one activity, for which activity would you be most willing to use glasses? Distance vision Mid-range vision Near vision Some people prefer to hold their reading material very close, while others prefer holding their reading material much farther away like in their laps. Try to estimate approximately how far from your face you prefer to hold your reading material. Note: The length of a sheet of paper from top to bottom is 11 inches. Use a sheet of paper as ruler to make a rough estimate. 11 inches (1 paper length) 16.5 inches (1 and a half paper lengths) 22 inches (2 paper lengths) If you could have good distance, mid-range, and near vision all without glasses, but the compromise was that you might see some halos, rings, or starbursts around lights at night, would you like that option? Yes No If you could have good distance and mid-range vision without glasses, but the compromise was that you might need glasses for the finest print at near, would you like that option? Yes No How would you best describe your personality? Easy going In the middle Perfectionist Comments This field is for validation purposes and should be left unchanged.