Questionnaire; personal vision habits and preferences (PDF)

Dr med. Jonas Stemmle FMH specialist in eye diseases FMH specialist in ophthalmic surgery FEBO Fellow of the European Board of Ophthalmology Augenarzt-Praxis Stemmle Address Kreuzplatz 1, 8032 Zurich Phone +41 44 201 66 44 Fax +41 44 201 66 53 E-mail [email protected] Web www.stemmle.com Patient label Questionnaire: personal vision habits and preferences 1. Do you wear a visual aid? Yes No If yes, what kind of visual aid do you wear? glasses contact lenses What activities do you need a visual aid for? (multiple answers possible) driving reading/writing reading the price tags when shopping other: working on computer mobile phone handicrafts 2. What is your occupation? / What occupation did you have in the past? 3. What hobbies do you pursue regularly? (multiple answers possible) reading working on computer painting hunting watching TV cooking golf shopping cycling handicrafts other: ____________________  Dr med. Jonas Stemmle FMH specialist in eye diseases FMH specialist in ophthalmic surgery FEBO Fellow of the European Board of Ophthalmology Augenarzt-Praxis Stemmle Address Kreuzplatz 1, 8032 Zurich Phone +41 44 201 66 44 Fax +41 44 201 66 53 E-mail [email protected] Web www.stemmle.com 4. Do you drive a car regularly? Yes No If yes, when and how often do you drive? During the day: frequently occasionally seldom At night: frequently occasionally seldom 5. Do you work on the computer for more than 3 hours a day? frequently occasionally never 6. How important is it to you not to have to wear glasses in everyday life? important not important 7. Would you like to be able to read without glasses after cataract surgery? Yes No 8. How would you describe yourself? On the following scale, please write an ‘X’ at the point that most closely matches your personality: tolerant perfectionist Thank you very much for your information!