PROWL Pre-Operative Questionnaire Form

Where are you taking this questionnaire?
In general, would you say your health is:
How often do you worry about your eyesight or vision?
How often do you notice or think about your eyesight or vision?
At this time, how clear is your vision using the correction you normally use, including glasses, contact lenses, a magnifier, or nothing 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.
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?
How much of the time do you expect to use glasses or contact lenses to see things up close after healing from LASIK surgery?
After healing from LASIK surgery, I expect that I will have clear vision:
After healing from LASIK surgery, I expect my vision to be perfect.
I could accept less than perfect vision if I did not need glasses or contact lenses any more after healing from LASIK surgery.
Have you ever driven a car?
Do you currently drive?
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?
Because of your vision, how much difficulty do you have driving during the daytime in familiar places?
Because of your vision, how much difficulty do you have driving at night?
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?
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?
Because of your vision, how much difficulty do you have with your daily activities?
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)?
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)?
Are there any recreational or sports activities that you don't do because of your vision or the type of vision correction you have?
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?
How much difficulty do you have reading ordinary print in newspapers?
How much difficulty do you have reading small print in a telephone book, on a medicine bottle, or on legal forms?
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?
How much difficulty do you have judging distances, like walking down stairs or parking a car?
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?
How much difficulty do you have seeing because of changes in the clarity of your vision during the course of the day?
How often are you bothered by changes in the clarity of your vision over the course of the day?
Have you experienced blurry vision in the last 7 days?
How bothersome has it been?
Have you experienced distorted vision in the last 7 days?
How bothersome has it been?
Have you experienced glare in the last 7 days?
How bothersome has it been?
Have you experienced trouble seeing in the last 7 days?
How bothersome has it been?
In general, how satisfied or dissatisfied are you with your present vision?
Are you currently employed (working for pay)?
In a typical day, select all that apply:
In the last 7 days, have you seen any double images?
In the last 7 days, how often have you seen double images when you are wearing your best vision correction (glasses or contact lenses)?
In the last 7 days, how often have you seen double images when you are NOT wearing any vision correction (glasses or contact lenses)?
In the last 7 days, how bothersome have the double images been when you are wearing your best vision correction (glasses or contact lenses)?
In the last 7 days, how bothersome have the double images been when you are NOT wearing any vision correction (glasses or contact lenses)?
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)?
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)?
When you use your best vision correction (glasses or contact lenses) do the double images you see:
In the last 7 days, have you noticed any glare?
In the last 7 days, how often have you noticed glare when you are wearing your best vision correction (glasses or contact lenses)?
In the last 7 days, how often have you noticed glare when you are NOT wearing any vision correction (glasses or contact lenses)?
In the last 7 days, how bothersome has the glare been when you are wearing your best vision correction (glasses or contact lenses)?
In the last 7 days, how bothersome has the glare been when you are NOT wearing any vision correction (glasses or contact lenses)?
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)?
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)?
When you use your best vision correction (glasses or contact lenses) does the glare you notice:
In the last 7 days, have you seen any halos?
In the last 7 days, how often have you seen halos when you are wearing your best vision correction (glasses or contact lenses)?
In the last 7 days, how often have you seen halos when you are NOT wearing any vision correction (glasses or contact lenses)?
In the last 7 days, how bothersome have the halos been when you are wearing your best vision correction (glasses or contact lenses)?
In the last 7 days, how bothersome have the halos been when you are NOT wearing any vision correction (glasses or contact lenses)?
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)?
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)?
When you use your best vision correction (glasses or contact lenses) do the halos you see:
In the last 7 days, have you seen any starbursts?
In the last 7 days, how often have you seen starbursts when you are wearing your best vision correction (glasses or contact lenses)?
In the last 7 days, how often have you seen starbursts when you are NOT wearing any vision correction (glasses or contact lenses)?
In the last 7 days, how bothersome have the starbursts been when you are wearing your best vision correction (glasses or contact lenses)?
In the last 7 days, how bothersome have the starbursts been when you are NOT wearing any vision correction (glasses or contact lenses)?
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)?
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)?
When you use your best vision correction (glasses or contact lenses) do the starbursts you see:
INSTRUCTIONS: During the last 7 days, how often have you experienced:
Eyes that are sensitive to light?
Eyes that feel gritty?
Painful or sore eyes?
Blurred vision?
Poor vision?
INSTRUCTIONS: During the last 7 days, how often have your eyes felt uncomfortable in:
Windy conditions?
Places or areas with low humidity (very dry)?
Areas that are air conditioned?
How do you get information about LASIK surgery? (please select all that apply)
Have you ever been told by a LASIK surgeon or any other eye care professional that you should not have LASIK surgery performed?
Over the last 2 weeks, how often have you been bothered by having little interest or pleasure in doing things?
Over the last 2 weeks, how often have you been bothered by feeling nervous, anxious, or on edge?
Over the last 2 weeks, how often have you been bothered by not being able to stop or control worrying?
INSTRUCTIONS: Listed below is a statement about your relationships with others. How much is this statement TRUE or FALSE for you?
I am always courteous even to people who are disagreeable.
No matter whom I'm talking to, I'm always a good listener.
In uncertain times, I usually expect the best.
It's easy for me to relax.
If something can go wrong for me, it will.
I'm always optimistic about my future.
I enjoy my friends a lot.
It's important for me to keep busy.
I hardly ever expect things to go my way.
I don't get upset too easily.
I rarely count on good things happening to me.
Overall, I expect more good things to happen to me than bad.
INSTRUCTIONS: Please select the answer you feel best applies to you.
If I don't master a task right away, I keep trying until I get it right.
I can adapt to new situations.
I am happy and content.
I am willing to take risks.
I look forward to trying a new task.
I feel self-assured and self-confident.
I like to try new places, activities, and situations.
I sleep well at night.
I am sure I can accomplish the tasks before me.
I can usually master a task even if I can't master it right away.
How did you feel about the length of the questionnaire?
I had no problem using the computer today.
Imagine you had been asked the same questions you were just asked by an interviewer rather than completing them by computer. Compared to answering these questions by an interviewer, how was answering them using the computer today?
What is the highest level of education you have completed?
Which category best describes your household income?
Are you Hispanic, Latino, or of Spanish origin?
What is your race? Please select all that apply.

Your test score is NaN