|
1.
|
How often do
you wear your glasses or contacts to see far away? |
|
Never
All
the time
1 2 3 4 5 6 7 8 9 10
|
|
2.
|
How
often do you wear glasses or contacts for near activities? |
|
Never
All
the time
1 2 3 4 5 6 7 8 9 10
|
|
3.
|
How
would you rate the quality of your vision without glasses? |
|
Poor Excellent
1 2 3 4 5 6 7 8 9 10
|
|
4.
|
How
would you rate the quality of your vision with glasses? |
|
Poor Excellent
1 2 3 4 5 6 7 8 9 10
|
|
5.
|
How
would you rate the quality of your vision with contacts? (if applicable) |
|
Poor Excellent
1 2 3 4 5 6 7 8 9 10
|
|
6.
|
Do
you have burning, stinging, irritation, or foreign body sensation
in your eyes? |
|
Never
All
the time
1 2 3 4 5 6 7 8 9 10
|
|
7.
|
Do
you experience dryness of your eyes with contact lenses with prolonged
wear? |
|
Never
All
the time
1 2 3 4 5 6 7 8 9 10
|
|
8.
|
How
often do you use artificial teardrops now? |
|
Never
All
the time
1 2 3 4 5 6 7 8 9 10
|
|
9.
|
Do
you experience halos or starbursts when you encounter bright light,
such as headlights, streetlights, etc.? |
|
No Severe
1 2 3 4 5 6 7 8 9 10
|
|
10.
|
How
does your vision affect your night driving? (with glasses or contacts
if applicable) |
|
No
Problem Difficult
to Drive
1 2 3 4 5 6 7 8 9 10
|
|
11.
|
How
heavily do you depend on your night vision? |
|
Not
much A
Great Deal
1 2 3 4 5 6 7 8 9 10
|
|
12.
|
Based
on your expectations for your vision after surgery, would that vision
be worth the possible risk of increased dryness and decreased night
vision after surgery? |
|
Not
at all
Definitely
1 2 3 4 5 6 7 8 9 10
|
