PROWL Post-Operative Questionnaire Form
Where are you taking this questionnaire?
Home
Doctor's office
Other location
In general, would you say your health is:
Excellent
Very good
Good
Fair
Poor
How often do you worry about your eyesight or vision?
Never
Rarely
Occasionally
Sometimes
All the time
How often do you notice or think about your eyesight or vision?
Never
Rarely
Occasionally
Sometimes
All the time
At this time, how clear is your vision using the correction you normally use, including glasses, contact lenses, a magnifier, or nothing at all?
Perfectly clear
Pretty clear
Somewhat clear
Not clear at all
As long as I could see well enough to drive without wearing glasses or contact lenses, I wouldn't mind having vision that was less than perfect.
Definitely true
Mostly true
Don't know
Mostly false
Definitely false
How much of the time do you expect to use glasses or contact lenses to see things in the distance after healing from LASIK surgery?
All of the time
Most of the time
Some of the time
Hardly ever
Never
How much of the time do you expect to use glasses or contact lenses to see things up close after healing from LASIK surgery?
All of the time
Most of the time
Some of the time
Hardly ever
Never
After healing from LASIK surgery, I expect that I will have clear vision:
All of the time
Most of the time
Some of the time
Hardly ever
Never
After healing from LASIK surgery, I expect my vision to be perfect.
Definitely true
Mostly true
Don't know
Mostly false
Definitely false
I could accept less than perfect vision if I did not need glasses or contact lenses any more after healing from LASIK surgery.
Definitely true
Mostly true
Don't know
Mostly false
Definitely false
Have you ever driven a car?
Yes
No
Do you currently drive?
Yes
No
If you gave up driving, was that mainly because of your vision, mainly for some other reason, or because of both your vision and other reasons?
Mainly vision
Mainly other reasons
Both vision and other reasons
Because of your vision, how much difficulty do you have driving during the daytime in familiar places?
No difficulty at all
A little difficulty
Moderate difficulty
A lot of difficulty
Never drive because of vision
Never drive for other reasons
Because of your vision, how much difficulty do you have driving at night?
No difficulty at all
A little difficulty
Moderate difficulty
A lot of difficulty
Never drive because of vision
Never drive for other reasons
Because of your vision, how much difficulty do you have driving in difficult conditions, such as bad weather, during rush hour, on the freeway, or in city traffic?
No difficulty at all
A little difficulty
Moderate difficulty
A lot of difficulty
Never drive because of vision
Never drive for other reasons
How much difficulty do you have seeing things off to the side, like cars coming out of driveways or side streets or people coming out of doorways?
No difficulty at all
A little difficulty
Moderate difficulty
A lot of difficulty
Never drive because of vision
Never drive for other reasons
Because of your vision, how much difficulty do you have with your daily activities?
No difficulty at all
A little difficulty
Moderate difficulty
A lot of difficulty
Never drive because of vision
Never drive for other reasons
Because of your vision, how much difficulty do you have taking part in active sports or other outdoor activities that you enjoy (like hiking, swimming, aerobics, team sports, or jogging)?
No difficulty at all
A little difficulty
Moderate difficulty
A lot of difficulty
Never drive because of vision
Never drive for other reasons
Because of your vision, do you take part less than you would like in active sports or other outdoor activities (like hiking, swimming, aerobics, team sports, or jogging)?
Yes
No
Are there any recreational or sports activities that you don't do because of your vision or the type of vision correction you have?
Yes, many
Yes, a few
No
You have noted that you have difficulty with your daily activities because of your vision. Please list those activities with which you have difficulty (e.g., watching television, using automated teller machines (ATM), etc.).
You have noted that you have difficulty with your daily activities because of your vision. Please list those activities with which you have difficulty (e.g., watching television, using automated teller machines (ATM), etc.).
How much difficulty do you have doing work or hobbies that require you to see well up close, such as cooking, fixing things around the house, sewing, using hand tools, or working with a computer?
No difficulty at all
A little difficulty
Moderate difficulty
A lot of difficulty
Never drive because of vision
Never drive for other reasons
How much difficulty do you have reading ordinary print in newspapers?
No difficulty at all
A little difficulty
Moderate difficulty
A lot of difficulty
Never drive because of vision
Never drive for other reasons
How much difficulty do you have reading small print in a telephone book, on a medicine bottle, or on legal forms?
No difficulty at all
A little difficulty
Moderate difficulty
A lot of difficulty
Never drive because of vision
Never drive for other reasons
Are there daily activities that you would like to do, but don't do, because of your vision or the type of vision correction you have?
Yes, many
Yes, a few
No
How much difficulty do you have judging distances, like walking down stairs or parking a car?
No difficulty at all
A little difficulty
Moderate difficulty
A lot of difficulty
Never drive because of vision
Never drive for other reasons
How much difficulty do you have getting used to the dark when you move from a lighted area into a dark place, like walking into a dark movie theater?
No difficulty at all
A little difficulty
Moderate difficulty
A lot of difficulty
Never drive because of vision
Never drive for other reasons
How much difficulty do you have seeing because of changes in the clarity of your vision during the course of the day?
Don't have changes in the clarity of my vision
No difficulty at all
A little difficulty
Moderate difficulty
A lot of difficulty
Never drive because of vision
Never drive for other reasons
How often are you bothered by changes in the clarity of your vision over the course of the day?
Never
Rarely
Occasionally
Sometimes
All the time
Have you experienced blurry vision in the last 7 days?
Yes
No
How bothersome has it been?
Very
Somewhat
A little
Not at all
Have you experienced distorted vision in the last 7 days?
Yes
No
How bothersome has it been?
Very
Somewhat
A little
Not at all
Have you experienced glare in the last 7 days?
Yes
No
How bothersome has it been?
Very
Somewhat
A little
Not at all
Because of your LASIK surgery, do you now have any problems or limitations that did not exist prior to LASIK surgery?
Yes
No
What problems or limitations do you have because of your LASIK surgery?
What problems or limitations do you have because of your LASIK surgery?
Have these problems or limitations affected the quality of your life?
Yes, the quality of my life has gotten a lot worse
Yes, the quality of my life has gotten a little bit worse
No, the quality of my life has not been affected
Yes, the quality of my life has gotten a little bit better
Yes, the quality of my life has gotten a lot better
In general, how satisfied or dissatisfied are you with your present vision?
Completely satisfied
Very satisfied
Somewhat satisfied
Somewhat dissatisfied
Very dissatisfied
Completely dissatisfied
Have you experienced trouble seeing in the last 7 days?
Yes
No
How bothersome has it been?
Very
Somewhat
A little
Not at all
Are you currently employed (working for pay)?
Yes
No
During the past seven days, how many hours did you miss from work because of any eye problems? HOURS
During the past seven days, how many hours did you miss from work because of any eye problems? HOURS
During the past seven days, how many hours did you miss from work because of any other reason, such as vacation, holidays, time off to participate in this study? HOURS
During the past seven days, how many hours did you miss from work because of any other reason, such as vacation, holidays, time off to participate in this study? HOURS
During the past seven days, how many hours did you actually work? HOURS
During the past seven days, how many hours did you actually work? HOURS
During the past seven days, how much did eye problems affect your productivity while you were working? Eye problem(s) 0 had no effect on my work - 10 Eye problem(s) completely prevented me from working
0
During the past seven days, how much did eye problems affect your ability to do your regular daily activities, other than work at a job? Eye problem(s) 0 had no effect on my daily activities - 10 Eye problem(s) completely prevented me from doing my regular activities
0
In a typical day, select all that apply:
I do not use glasses or contact lenses
I use glasses to correct my vision for distance
I use glasses to correct my vision for reading
I use soft contact lenses to correct my vision for distance
I use soft contact lenses to correct my vision for reading
I use hard (rigid gas permeable) contact lenses to correct my vision for distance
I use hard (rigid gas permeable) contact lenses to correct my vision for reading
In the last 7 days, have you seen any double images?
Yes, but ONLY when NOT wearing glasses or contact lenses
Yes, but ONLY when wearing glasses or contact lenses
Yes, when wearing AND when not wearing glasses or contact lenses
No, not at all
In the last 7 days, how often have you seen double images when you are wearing your best vision correction (glasses or contact lenses)?
I do not use glasses or contact lenses
Never
Rarely
Sometimes
Often
Always
In the last 7 days, how often have you seen double images when you are NOT wearing any vision correction (glasses or contact lenses)?
I do not use glasses or contact lenses
Never
Rarely
Sometimes
Often
Always
In the last 7 days, how bothersome have the double images been when you are wearing your best vision correction (glasses or contact lenses)?
I do not use glasses or contact lenses
Extremely bothersome
Very bothersome
Somewhat bothersome
A little bothersome
Not at all bothersome
In the last 7 days, how bothersome have the double images been when you are NOT wearing any vision correction (glasses or contact lenses)?
I do not use glasses or contact lenses
Extremely bothersome
Very bothersome
Somewhat bothersome
A little bothersome
Not at all bothersome
In the last 7 days, how much difficulty have you had doing your usual activities because you see double images when you are wearing your best vision correction (glasses or contact lenses)?
I do not use glasses or contact lenses
No difficulty at all
Very little difficulty
Moderate difficulty
A lot of difficulty
So much difficulty that I can no longer do some of my usual activities
In the last 7 days, how much difficulty have you had doing your usual activities because you see double images when you are NOT wearing any vision correction (glasses or contact lenses)?
I do not use glasses or contact lenses
No difficulty at all
Very little difficulty
Moderate difficulty
A lot of difficulty
So much difficulty that I can no longer do some of my usual activities
When you use your best vision correction (glasses or contact lenses) do the double images you see:
I do not use glasses or contact lenses
Go away completely
Go away mostly
Go away a little
Not change
Get a little worse
Get a lot worse
In the last 7 days, have you noticed any glare?
Yes, but ONLY when NOT wearing glasses or contact lenses
Yes, but ONLY when wearing glasses or contact lenses
Yes, when wearing AND when not wearing glasses or contact lenses
No, not at all
In the last 7 days, how often have you noticed glare when you are wearing your best vision correction (glasses or contact lenses)?
I do not use glasses or contact lenses
Never
Rarely
Sometimes
Often
Always
In the last 7 days, how often have you noticed glare when you are NOT wearing any vision correction (glasses or contact lenses)?
I do not use glasses or contact lenses
Never
Rarely
Sometimes
Often
Always
In the last 7 days, how bothersome has the glare been when you are wearing your best vision correction (glasses or contact lenses)?
I do not use glasses or contact lenses
Extremely bothersome
Very bothersome
Somewhat bothersome
A little bothersome
Not at all bothersome
In the last 7 days, how bothersome has the glare been when you are NOT wearing any vision correction (glasses or contact lenses)?
I do not use glasses or contact lenses
Extremely bothersome
Very bothersome
Somewhat bothersome
A little bothersome
Not at all bothersome
In the last 7 days, how much difficulty have you had doing your usual activities because you noticed glare when you are wearing your best vision correction (glasses or contact lenses)?
I do not use glasses or contact lenses
No difficulty at all
Very little difficulty
Moderate difficulty
A lot of difficulty
So much difficulty that I can no longer do some of my usual activities
In the last 7 days, how much difficulty have you had doing your usual activities because you notice glare when you are NOT wearing any vision correction (glasses or contact lenses)?
I do not use glasses or contact lenses
No difficulty at all
Very little difficulty
Moderate difficulty
A lot of difficulty
So much difficulty that I can no longer do some of my usual activities
When you use your best vision correction (glasses or contact lenses) does the glare you notice:
I do not use glasses or contact lenses
Go away completely
Go away mostly
Go away a little
Not change
Get a little worse
Get a lot worse
In the last 7 days, have you seen any halos?
Yes, but ONLY when NOT wearing glasses or contact lenses
Yes, but ONLY when wearing glasses or contact lenses
Yes, when wearing AND when not wearing glasses or contact lenses
No, not at all
In the last 7 days, how often have you seen halos when you are wearing your best vision correction (glasses or contact lenses)?
I do not use glasses or contact lenses
Never
Rarely
Sometimes
Often
Always
In the last 7 days, how often have you seen halos when you are NOT wearing any vision correction (glasses or contact lenses)?
I do not use glasses or contact lenses
Never
Rarely
Sometimes
Often
Always
In the last 7 days, how bothersome have the halos been when you are wearing your best vision correction (glasses or contact lenses)?
I do not use glasses or contact lenses
Extremely bothersome
Very bothersome
Somewhat bothersome
A little bothersome
Not at all bothersome
In the last 7 days, how bothersome have the halos been when you are NOT wearing any vision correction (glasses or contact lenses)?
I do not use glasses or contact lenses
Extremely bothersome
Very bothersome
Somewhat bothersome
A little bothersome
Not at all bothersome
In the last 7 days, how much difficulty have you had doing your usual activities because you see halos when you are wearing your best vision correction (glasses or contact lenses)?
I do not use glasses or contact lenses
No difficulty at all
Very little difficulty
Moderate difficulty
A lot of difficulty
So much difficulty that I can no longer do some of my usual activities
In the last 7 days, how much difficulty have you had doing your usual activities because you see halos when you are NOT wearing any vision correction (glasses or contact lenses)?
I do not use glasses or contact lenses
No difficulty at all
Very little difficulty
Moderate difficulty
A lot of difficulty
So much difficulty that I can no longer do some of my usual activities
When you use your best vision correction (glasses or contact lenses) do the halos you see:
I do not use glasses or contact lenses
Go away completely
Go away mostly
Go away a little
Not change
Get a little worse
Get a lot worse
In the last 7 days, have you seen any starbursts?
Yes, but ONLY when NOT wearing glasses or contact lenses
Yes, but ONLY when wearing glasses or contact lenses
Yes, when wearing AND when not wearing glasses or contact lenses
No, not at all
In the last 7 days, how often have you seen starbursts when you are wearing your best vision correction (glasses or contact lenses)?
I do not use glasses or contact lenses
Never
Rarely
Sometimes
Often
Always
In the last 7 days, how often have you seen starbursts when you are NOT wearing any vision correction (glasses or contact lenses)?
I do not use glasses or contact lenses
Never
Rarely
Sometimes
Often
Always
In the last 7 days, how bothersome have the starbursts been when you are wearing your best vision correction (glasses or contact lenses)?
I do not use glasses or contact lenses
Extremely bothersome
Very bothersome
Somewhat bothersome
A little bothersome
Not at all bothersome
In the last 7 days, how bothersome have the starbursts been when you are NOT wearing any vision correction (glasses or contact lenses)?
I do not use glasses or contact lenses
Extremely bothersome
Very bothersome
Somewhat bothersome
A little bothersome
Not at all bothersome
In the last 7 days, how much difficulty have you had doing your usual activities because you see starbursts when you are wearing your best vision correction (glasses or contact lenses)?
I do not use glasses or contact lenses
No difficulty at all
Very little difficulty
Moderate difficulty
A lot of difficulty
So much difficulty that I can no longer do some of my usual activities
In the last 7 days, how much difficulty have you had doing your usual activities because you see starbursts when you are NOT wearing any vision correction (glasses or contact lenses)?
I do not use glasses or contact lenses
No difficulty at all
Very little difficulty
Moderate difficulty
A lot of difficulty
So much difficulty that I can no longer do some of my usual activities
When you use your best vision correction (glasses or contact lenses) do the starbursts you see:
I do not use glasses or contact lenses
Go away completely
Go away mostly
Go away a little
Not change
Get a little worse
Get a lot worse
INSTRUCTIONS: During the last 7 days, how often have you experienced:
Eyes that are sensitive to light?
None of the time
Some of the time
Half of the time
Most of the time
All of the time
Eyes that feel gritty?
None of the time
Some of the time
Half of the time
Most of the time
All of the time
Painful or sore eyes?
None of the time
Some of the time
Half of the time
Most of the time
All of the time
Blurred vision?
None of the time
Some of the time
Half of the time
Most of the time
All of the time
Poor vision?
None of the time
Some of the time
Half of the time
Most of the time
All of the time
INSTRUCTIONS: During the last 7 days, how often have your eyes felt uncomfortable in:
Windy conditions?
None of the time
Some of the time
Half of the time
Most of the time
All of the time
Places or areas with low humidity (very dry)?
None of the time
Some of the time
Half of the time
Most of the time
All of the time
Areas that are air conditioned?
None of the time
Some of the time
Half of the time
Most of the time
All of the time
Did your surgeon or health provider from this surgeon’s office explain what to expect during your recovery period from LASIK surgery?
Yes, definitely
Yes, somewhat
No
Currently, how satisfied or dissatisfied are you with the result of your LASIK surgery?
Completely satisfied
Very satisfied
Somewhat satisfied
Somewhat dissatisfied
Very dissatisfied
Completely dissatisfied
Never had any improvement in my vision after LASIK surgery
Currently, how satisfied or dissatisfied are you with how long it took to see improvement in your vision after LASIK surgery?
Completely satisfied
Very satisfied
Somewhat satisfied
Somewhat dissatisfied
Very dissatisfied
Completely dissatisfied
Never had any improvement in my vision after LASIK surgery
Currently, how satisfied or dissatisfied are you with how long it took to see improvement in your post-operative symptoms of discomfort after LASIK surgery?
Completely satisfied
Very satisfied
Somewhat satisfied
Somewhat dissatisfied
Very dissatisfied
Completely dissatisfied
Never had any improvement in my vision after LASIK surgery
How well do you feel you understood the risks and benefits of the LASIK procedure before treatment?
Completely understood
Somewhat understood
Somewhat misunderstood
Completely misunderstood
When you are not wearing glasses or contact lenses, is your distance vision now as good as you anticipated it would be after LASIK surgery?
Yes, definitely
Yes, somewhat
No
Are you currently wearing glasses or contact lenses to see things in the distance?
No, none of the time
Yes, some of the time
Yes, most of the time
Yes, all of the time
Did you achieve the goals you had for LASIK surgery?
Yes, fully achieved
Yes, partially achieved
No
How happy or unhappy are you that you had LASIK surgery?
Completely happy
Very happy
Somewhat happy
Somewhat unhappy
Very unhappy
Completely unhappy
If you could do it all over again, would you decide to have LASIK performed?
Yes, I would decide to have it again, because of my result.
Yes, I would decide to have it again, despite my result.
No, I would not decide to have it again, because of my result.
No, I would not decide to have it again, despite my result.
Would you recommend LASIK surgery to a friend or family member?
Yes, I would recommend it because of my result.
Yes, I would recommend it despite my result.
No, I would not recommend it because of my result.
No, I would not recommend it despite my result.
Why would you not have LASIK done again or not recommend it to a friend or family member? (please select all that apply)
Did not like the facility
Did not like the surgeon
Did not like the staff
Did not like the procedure
Did not like the results
Other
Over the last 2 weeks, how often have you been bothered by having little interest or pleasure in doing things?
Not at all
Several days
More than half the days
Nearly every day
Over the last 2 weeks, how often have you been bothered by feeling nervous, anxious, or on edge?
Not at all
Several days
More than half the days
Nearly every day
Over the last 2 weeks, how often have you been bothered by not being able to stop or control worrying?
Not at all
Several days
More than half the days
Nearly every day
Your test score is
NaN
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