"Dr Rom is an excellent Physician, he is the best there is. I received the best care from the initial exam through the post op and continue to receive excellent care."
--Julie Wichert, Huntsburg, Ohio
Lifestyle Questionnaire
The following questionnaire will help you think about how you use your eyes in order for you and your ophthalmologist to determine the best option for you.
1. Do you mind wearing glasses?
Yes No
2. Would you be content knowing you may need glasses for some tasks?
Yes No
3. Do you do a lot of night driving?
Yes No
4. Do you use a computer on a daily basis?
Yes No
5. Do you play golf or any other sports?
Yes No
6. Do you do a lot of close detail work such as sewing, knitting, engineering, drawing, or building models?
Yes No
7. Have you ever tried monovision contact lenses?
Yes No
8. Do you notice halos or rings around lights when driving at night?
Yes No
9. How would you describe your personality?
Very easy going
Detail and perfection oriented
Somewhere in between
10. If you had to wear glasses after surgery for one activity, for which activity would you be most willing to use glasses?
Reading fine print
Computer
Driving
11. If you could have a good distance vision during the day without glasses, and good near vision for
reading without glasses, but the compromise was that you might see some halos around lights at
night, would you like that option?
Yes No
12. If you could have good distance vision during the day and night without glasses, and good computer
distance vision without glasses, but the compromise was that you might need glasses for reading
the finest print at near vision, would you like that option?
Yes No
If you click on the SUBMIT button, your questionnaire answers will be sent to Insight Eye Center
and someone will call you for an appointment to review your vision options.
YOU HAVE THE QUESTIONS
AND WE HAVE THE ANSWERS!
CALL US TODAY Mentor (440) 205-5840 Chardon (440) 286-1188
OR EMAIL US:
