Cataract Questionnaire

Cataract and Refractive Lens Questionnaire

The term “cataract” refers to a cloudy lens within the eye. When a cataract is removed, it is replaced with an artificial lens. If surgery is appropriate for you, this questionnaire will help us provide the best treatment for your visual needs. It is important to understand that many patients still need glasses for some activities after surgery. In order to have a cataract consultation you will need a current eye exam from your optometrist faxed over to our office for a referral. Our Fax# (843) 449-7614.

Please fill this form out completely.

Name(Required)
Phone
Email(Required)
Have you had a complete eye exam within the last 1.5 years?(Required)
Do you currently wear glasses or contact lenses regularly?(Required)
After surgery, would you be interested in seeing well without glasses in the following situations?
Distance Vision (driving, golf, watching TV)
Mid-range Vision (computer, menus, cooking)
Near Vision (reading books, smartphones, tablets, sewing)
Please check the single statement that best describes you in terms of night vision:
Some people prefer to hold their reading material very close, while others prefer holding their reading material much farther away, in their laps. How far away do you hold a book?
If you could have good Distance, Mid-range, and/or 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?
If you could have good Distance and Mid-range Vision without glasses, but the compromise was that you might need glasses for small print at near, would you like that option?
1= Easy going 10= Perfectionist
Consent(Required)