Cataract Self-Test: John-Kenyon

1

What is your age group?* This field is required.

18 or under

19-39

40-59

60+

2

Do you wear...* This field is required.(check all that apply)

Glasses

Contacts

Reading glasses

None of these

3

Without my glasses and contacts...* This field is required.(check all that apply)

I have trouble reading and seeing things close up (Farsightedness)

I have trouble driving and seeing things far away (Nearsightedness)

I have distorted vision and cannot see very well (Astigmatism)

5

Have you been told you have cataracts and require surgery?* This field is required.

YESNO

6

Would you like see better at a distance?* This field is required.(without relying on glasses and contact lenses)

YESNO

7

Would you like to see better close up?* This field is required.(without relying on glasses and contact lenses)

YESNO

8

Is it important to see well at night?* This field is required.(without relying on glasses and contact lenses)

YESNO

9

Name* This field is required.

First Name

Last Name

10

Email* This field is required.

example@example.com

11

Do they qualify?