Premium Lens Self Evaluation

Grove Medical Arts Building, 4th Floor, Suite 401, 12665 Garden Grove Blvd., Garden Grove, CA 92843

Name:
Phone:
E-Mail:

How interested are you in seeing at a distance, driving or playing golf without glasses after your cataract surgery?
It's very important to me NOT to wear glasses for distance vision.

It's not important to me. I do not mind wearing glasses.
Are you interested in seeing well up close (reading) without glasses after your cataract surgery?
It's very important to me NOT to wear reading glasses.

It's not important to me. I do not mind wearing reading glasses to see things up close.
If you had to wear glasses after your vision treatment for one of the following activities, which one would you most be willing to wear glasses for?
Reading fine print

Using a computer or cooking

Driving a car
If you could have good vision for driving during the day without glasses, and good near vision without glasses in most situations, would you be able to tolerate some halos and glare around lights at night?
Yes

No
If you could have good distance vision day and night, and good vision for computer work, without glasses, would you be willing to wear glasses for reading fine print and small type?
Yes

No
In our daily lives there are different things we do that require us to SEE at different distances. We have grouped some of these vision activities into 5 lifestyle zones. Think about the things in life you want to do the most without depending on glasses after cataract surgery. Which group is the most important
Newsprint, books, reading maps or sewing.

Computer screens, menus, price tags or headlines.

Watching TV, cooking, cleaning or indoor activties.

Driving, playing golf, seeing road signs.

Night Driving, watching movies.
Consider your personality. Based on the options scale below how would you rank your personality?
Easy Going

In the middle

Perfectionist

Orange County Cataract Surgery with ReSTOR IOL. Experience clear vision after cataract surgery with a multifocal IOL.

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Full Service Optical Shop in Garden Grove. Providing the latest in eyeglasses and sunglasses from the top designer brands.

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Always seek the advice of your physician or other qualified health care provider.