Am I a Good Multifocal Lens Candidate?
Please fill out then print this checklist, and bring it with you for your Consultation.
Without glasses or contact lenses…
| Yes | No | |
| Do you have trouble seeing at distance? | ||
| Do you have trouble seeing up close? | ||
| Do you have night vision problems? | ||
| If yes, please describe: |
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| Do you have dry eye problems? | ||
| If yes, please describe: |
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| Have you noticed a change in your vision over the last year? | ||
| If yes, please describe: |
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| Do you have severe diabetes or severe allergies? | ||
| Do you have any active eye diseases, for example glaucoma or macular degeneration? | ||
| Do you have collagen vascular, autoimmune or immunodeficiency diseases, such as Rheumatoid arthritis, Lupus or AIDS? | ||
| Do you show signs of keratoconus (corneal disease)? | ||
| Do you have Vision Insurance?If yes, please provide Front Desk with Benefits card so that we may make a copy. | ||
| Would you be satisfied if your natural vision was greatly improved even if you still had to wear corrective lenses some of the time? | ||
| Do your glasses or contacts interfere with your recreational activities? | ||
| If yes, which activities: |
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| Is it acceptable to you that you may need glasses for reading after your Lens surgery? | ||
| Do you have vision problems with reading or computer work? | ||
| If yes, please describe: |
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| Do you have vision issues, limitation, or restrictions with your work or profession? | ||
| If yes, please describe: |
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