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Cataract Surgery Candidacy
Cataracts
>
Cataract Surgery Candidacy
Sub Title
Name
Email
Phone
Are you having trouble with your vision? *
Yes
No
Have you had any previous eye operations (Refractive surgery/LASIK, or lasers)? *
Yes
No
Do you currently wear anything to correct your vision? *
Reading glasses only
Glasses (Distance, bi-focals, tri-focals or progressive)
Contact Lenses
No correction
Have you been told you have cataracts and require surgery? *
Yes
No
Think about your vision when looking in the distance (driving, playing golf). How important is it for you to do these tasks without glasses after surgery? *
I am very interested in not wearing reading glasses
I am moderately interested in not wearing reading glasses
I don't mind wearing glasses, so it is not important to me
How important is clear night vision for you after cataract surgery? *
Very Important
Moderately Important
Not Important
Below are 4 zones of vision. Consider things in life you want to do without dependence on glasses, which group is most important to your lifestyle? *
Select All
Far
Intermediate
Near
Very Near
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Westlake Village
Camarillo
Simi Valley
Encino
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Newbury Park
DLV Surgical Center
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(805) 987-5300
818-874-3048
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