Cataracts Self-Test Please enter your information to see your results!Name* Email* Phone Number* 1. What is your age group?* 19-39 40-59 60+ 2. I have been experiencing... (check all that apply)* NIGHTTIME GLARE, HALO, OR STARBURST PATTERNS DIFFICULTY DRIVING AT NIGHT FREQUENT PRESCRIPTION CHANGES IN THE PAST 1-2 YEARS DECREASED VISION IN LOW LIGHT A CHANGE IN MY VISION NO PROBLEMS WITH MY VISION 3. Without my glasses and contacts, I have difficulty... (check all that apply)* SEEING ALL DISTANCES SEEING FAR AWAY (DRIVING, ETC.) SEEING CLOSE UP (READING, ETC.) 4. I usually wear… (check all that apply)* Glasses Contacts Reading Glasses I DON'T NEED GLASSES OR CONTACTS FORANY DISTANCE 5. Are the following statements important to you?I would like to see well at a distance without relying on glasses and contact lenses.* Yes No I'm not sure I would like to see well up close without relying on glasses and contact lenses.* Yes No I'm not sure It is important to me to see well at night after cataract surgery.* Yes No I'm not sure 6. Which abilities do you want to be able to do WITHOUT using glasses? (check all that apply)* ALL OF THE ABOVE SEEING VERY CLOSE (CRAFTS, PUZZLES, ETC.) SEEING CLOSE UP (READING, ETC.) SEEING INTERMEDIATE DISTANCES (COOKING, ETC.) SEEING FAR AWAY (DRIVING, SPORTS, ETC.)
