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Cataract Self-Test

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1.How interested are you in seeing at a distance, driving or playing golf without glasses after your cataract surgery?
2.Are you interested in seeing well up close (reading) without glasses after your cataract surgery?
3.If you had to wear glasses after your vision treatment for one of the following activities, which one would you to most be willing to wear glasses for?
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?
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?
6.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
7. Consider your personality. Based on the options scale below how would you rank your personality?
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Quick Help Form

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First Name*
Last Name*
Phone*
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Do we have permission to text with you?*
*Hours may vary. Please contact us for questions about scheduling
Date of Birth
MM slash DD slash YYYY
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Self Assessment Test

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Step 1 of 7

14%

What is your age?(Required)

17 or younger

17 or younger

18-40

18-40

41-64

41-64

65 or older

65 or older

What do you have trouble seeing without glasses or contact lenses?(Required)

I can’t see far

I can’t see far

I can’t see near

I can’t see near

I can’t see anything

I can’t see anything

What do you wear the most?(Required)

Glasses

Glasses

Contact lenses

Contact lenses

Glasses and contact lenses

Glasses and contact lenses

Nothing

Are you generally healthy?(Required)

Yes

Yes

No

If no, what health problems do you have?

Have you ever had an eye surgery or injury in the past?(Required)

Yes

Yes

No

If yes, what surgery or injury?

Why do you want to no longer need glasses or contact lenses?

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Contact Us

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First Name*
Last Name*
Phone*
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Procedure of Interest*
DOB
Month
Day
Year
Insurance information (carrier and policy number)*
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Do we have permission to text with you?*
*Hours may vary. Please contact us for questions about scheduling

Request Consultation

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*Hours may vary. Please contact us for questions about scheduling

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6402 Arlington Blvd Suite 600
Falls Church, VA 22042

11713 Bowman Green Drive
Reston, VA 20190

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LASIK
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First Name(Required)
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Phone(Required)
Date of Birth(Required)
Month
Day
Year
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Street Address
City
State
Insurance Company(Required)
Policy ID Number
Is the patient the insurance holder?(Required)
How did you hear about us?(Required)
Referring provide, Name (If Applicable)(Required)
Reason For Appointment(Required)
Preferred Locations(Required)
Provider to see(Required)
Preferred Day of Week(Required)
Preferred time of day(Required)
Message
Procedure of Interest
Do we have permission to text with you?(Required)

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