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Yes |
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No |
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1. Do you have trouble with distance vision? |
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2. Do you have trouble seeing up close? |
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3. Do you wear reading glasses for close work? |
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If yes, how many years have you been wearing them? |
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4. Do you have night vision problems? |
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If yes, please describe: |
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5. Do you have dry eyes? |
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If yes, please describe: |
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6. Are certain sports or hobbies you're interested in
compromised by your near vision? |
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If yes, please describe: |
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7. Do you have severe diabetes or severe allergies? |
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8. Do you have any active eye diseases, for example glaucoma
or cataracts, or other health problems such as collagen,
vascular, autoimmune or immunodeficiency diseases
(for example: Rheumatoid arthritis, Lupus, AIDS)? |
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9. Would you be satisfied with a procedure that allows you to
function in daily life without reading glasses, but still requires
you to use them for prolonged close work? |
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| 10. What type of work do you do? |
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| 11. How many hours per day do you spend on the computer? |
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| 11. How many hours per day do you spend reading, either for business or for pleasure? |
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13. Describe any vision issues that occur when driving?
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