If you feel that cataracts may be affecting your vision, call us today at (440) 255-1115 to schedule a cataract consultation. During your visit, we will conduct a thorough eye exam. We will examine the overall health of your eyes and your ability to see up-close and at a distance. If we determine you have a visually significant cataract, we will discuss with you all of your options for treatment based on your lifestyle and eye health.

One of the most important parts of your cataract consultation and exam is to understand your vision and lifestyle needs. Please print out and complete the Lifestyle Questionnaire below and bring it with you when you come for your consultation. We will make every effort to understand what is important to you and recommend a vision solution to meet your individual needs.

 

Thank you for choosing Ophthalmic Physicians, Inc. for your eye care.

We look forward to seeing you at your upcoming appointment.

OPI Patient Vision and Lifestyle Questionnaire

Name __________________________________   Date __________________________

1. What type of glasses do you presently wear?

    _____None     _____Bi-Focal     _____Tri-Focal     _____Reading only     _____Distance only

2. Do you mind wearing glasses?

    _____Yes     _____No

3. Would you be content knowing you need glasses for some tasks?

    _____Yes     _____No

4. Are you interested in seeing well at near without glasses after surgery?

    _____Yes     _____No

5. Are you interested in seeing well at distance without glasses after surgery?

    Yes     _____No

6. If you had to wear glasses after surgery for one activity, for which activity would you be most willing to wear glasses?

    _____Reading fine print     _____Using the computer     _____Driving

7. Do you see halos or rings around lights when driving at night?

    _____Yes     _____No

8. If you could become relatively independent from using glasses, but the compromise would be that you may see halos around lights at night, would you like that option?

    _____Yes     _____No

9. How often do you do the following activities?

  Often Sometimes Rarely
Reading ______ ______ ______
Close detail work ______ ______ ______
Computer ______ ______ ______
Watch TV ______ ______ ______
Outdoor activities ______ ______ ______
Night driving ______ ______ ______

10. Please place an ”X” on the following scale to describe your personality.

[ ----------------------------------------------- | ------------------------------------------------- ]

Easy Going                                                   Perfectionist

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