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Lifestyle Lens Questionnaire

Use the Chart Below to answers questions 1-3:

 

Zone 1 Zone 2 Zone 3

Near 16 inches and closer

 

Reading

Applying Makeup

Cell Phone

Intermediate 16inches to 20ft

 

Computer Work

Shopping

Playing Cards

Watching TV

Distance 20ft and beyond

 

Driving

Watching Movies

Golfing

Sporting Events

1. If after surgery you could see well without glasses at 2 of the 3 options, which two would you choose? 2. Which “zone” of vision is most important to you? 3. If you had to wear glasses after surgery which zonewould you choose? 4. Describe your current vision (select all that apply). 5. What outcome are you looking for with cataract surgery(select all that apply)? 6. Yes, I would like to schedule a cataract evaluation.The best time to call me is: 7. Please provide us withyour contact information: -- 9. Would you like to receive a Free Cataract Information Kit?