Premium Lifestyle Lens Questionnaire Name Phone E-mail Best Time to Contact Morning Afternoon Evening 1. 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. 2. 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. 3. 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. 4. 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 5. 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 6. Consider your personality. Based on the options scale below how would you rank your personality? Easy Going In the middle Perfectionist 7. We Divide vision into 5 "Zones of Vision" Near Far Zone 1 (12-20 in) Newsprint Phonebook Maps Sewing Zone 2 (2 - 4 ft) Headlines Computer Menus Price tags Zone 3 (6 - 20ft) Indoors TV Cooking Cleaning Zone 4 (20 - 100ft) Day-Far Driving Golf Road Signs Zone 5 (100ft+) Night-driving Night-far Movies Star Gazing 8. Which group of "Zones of Vision" is the most important to you? Please choose only one of the following options of Group A, B or C. Group A: Zones 1, 2 and 3 Group B: Zones 2, 3 and 4 Group C: Zones 3, 4 and 5
