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| Patient Name: |
| Age: |
| Race: |
| Gender: |
| Job/No Job: |
| Did they attend college: |
| How long they’ve been diabetic: |
| How long they have seen Dr. Mason: |
| Vision: |
| How many doctors do they have: |
| How many lasers have they received: |
| How many shots have they received: |
| Insurance carrier: |
| 1. Which made you more anxious before you had either procedure (circle one): laser or shot |
| 2. Which makes you more anxious now that you’ve had both (circle one): laser or shot |
| 3. Which works better? (circle one) laser or shot |
| 4. Which do you prefer? Laser or shot Why? |
| 5. Which is easier for you? (circle one) laser or shot |
| 6. If three lasers did not make you see quite as well as 15-16 shots, which would you pick? (circle one) Lasers or shots |
| 7. How many lines on the eye chart would you be willing to give up in order to receive just 3 lasers as opposed to 15-16 shots? |
| 8. Would you be willing to lose one line of vision on the eye chart so you didn’t have to come in every month for a shot? Y N |
| 9. Would you be willing to lose two lines of vision on the eye chart so you didn’t have to come in every month for a shot? Y N |
| 10. Would you be willing to lose three lines of vision on the eye chart so you didn’t have to come in every month for a shot? Y N |
| 11. Is it worth 15-16 shots to gain on average 2 lines of vision? Y N |
| 12. On a scale of 1-5, what is the chance you can visit for 15-16 shots over 2 years? (1=most likely; 5=least likely) |
| 13. On a scale of 1-5, what is the chance you can visit for 7 shots and 3 lasers over 2 years? (1=most likely; 5=least likely) |
| 14. On a scale of 1-5, what is the chance you can visit for 4 lasers over 2 years? (1=most likely; 5=least likely) |
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