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(Enter the letters as they are shown in the image above.)

This is a standard questionnaire that I think it is important to keep the same.

After cataract surgery, are you interested in seeing at a distance without having to wear glasses? For example, would you like to drive, play tennis or golf, etc. without having to wear glasses?

	Yes, it is very important to me NOT to wear glasses for such distance activities.
	No, it is not important to me. I don’t mind wearing glasses for distance vision.

After cataract surgery, are you interested in seeing well up close (reading) without glasses?

	Yes, NOT wearing reading glasses is very important to me.
	No, it is not important to me. I don’t mind wearing glasses for up-close vision.

Imagine that you must wear glasses after your cataract surgery for certain activities. Which of the following activities would you be most willing to wear glasses for?

	The reading of small fine print.
	The use of a computer.
	Watching a movie or driving a car.

Imagine that you could enjoy good vision in most circumstances without glasses. You do not need glasses for day-time driving. Your up-close vision does not require glasses for most everyday situations such as reading normal-size print. In this situation, do you feel that you could tolerate some glare and/or halos around lights at night?

	Yes, I could tolerate some glare and/or halos around lights at night.
	No, I could NOT tolerate some glare and/or halos around lights at night.

Imagine that you could enjoy good vision during the day and night. You also could have good vision for computer work without glasses. In this situation, do you feel that you could tolerate wearing reading glasses for reading fine print?

	Yes, I could tolerate wearing reading glasses in this situation.
	No, I could NOT tolerate wearing reading glasses in this situation.

We have a variety of vision activities to perform during our everyday lives. These activities require us to see at different distances. To get a better understanding of your goals, we have grouped many daily vision activities into 5 zones. Which group of activities is it most important for you to do without glasses if possible?

	Reading books, maps, newspapers or sewing.
	Reading headlines, price tags, computers screen.
	Cleaning, cooking, watching TV, or other indoor activities.
	Playing golf or tennis, driving during the day, seeing road signs.
	Watching movies. Driving at night.

Please rate your personality.

	Relaxed and/or Easy Going
	Somewhere In the middle
	Compulsive and/or Perfectionist.

Is there any other information you would like us to know?


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