Cataract Self Evaluation | Willis Falkenberg EyeCare

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Cataract IOL Self Test Evaluation

The following IOL Self-Test will help us determine which artificial intraocular lens would be best for you after your cataract surgery. Please fill out this form and email it back to us or print it out after completion and bring it in with you at your upcoming appointment.

Name:
Phone:
E-Mail:

1. If you had to wear glasses after your cataract surgery, which one of the following activities would you be most willing to wear glasses to do?

Read a menu
Work at the computers
Drive

2. Which one of these activities would you be least willing to wear glasses to do?

Read a menu
Work at the computer
Drive

3. If you could have good distance vision, intermediate vision and near vision without glasses during the day, but you might see some rings and halos around lights at night would you be OK with this side-effect?

Yes
No
Probably

4. If you could have good distance and intermediate vision but you might need glasses to read fine print, would you be OK with this result?

Yes
No
Probably

5. If you could classify your personality with the choices below, which one describes you best?

Very laid back
Willing to compromise when necessary
My way or the highway

6. What is your age range?

40 - 50 years old
50 - 65 years old
65+ years

10 Chatham Heights Rd. • Fredericksburg, VA 22405 • 540-371-2777