ReSTOR Questionare

1. Does wearing glasses bother or frustrate you?	Yes	No	Somewhat
2. Are you interested in surgery to reduce your need for glasses?	Yes	No	Somewhat
3. Would it bother you to wear glasses for some tasks after surgery?	Yes	No	Somewhat
4. Do you do a lot of night driving?	Yes	No	Somewhat
5. Do you notice halos or glare around lights while driving at night?	Yes	No	Somewhat
6. Would halos or glare around lights at night bother you after surgery?	Yes	No	Somewhat
7. Do you use a computer on a daily basis?	Yes	No	Somewhat
8. Do you do a lot of close detail work	Yes	No	Somewhat
9. Have you ever tried monovision contact lenses?	Yes	No	Now Using
9a. If “yes”, did/do you like it?	Yes	No

10. Check only two (2) ranges you would most prefer to see without glasses:

Far	Intermediate	Near	Other
Driving	Comptuer	Newsprint	Night Driving
Television	Cooking	Cell Phone	Star Gazing
Sightseeing	Makeup	Maps	Dim Light, far
Movies	Price Tags	Sewing	Dim Light, near
Outdoors	Looking in Mirror	Prescription Lables	Sharp-Shooting

11. Would you like to have, without glasses, good distance vision during the day, and good near vision for reading in good light, even if you might see some halos or glare around lights at night?

Yes

Maybe

12. How would you describe your personality?

Easy going

Perfectionist

In between the two

13. Please inital one:

____ I AM interested in surgery to help reduce my need for glasses. I understand insurance does NOT pay for this option. Any additional cost related to reducing my need for glasses is “out-of-pocket.”

____ I AM NOT interested in surgery to help reduce my need for glasses. I understand after cataract surgery my glasses prescription will change and I will likely need glasses for most everything.

Date______________________________

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