Name
First & Last Name
Name
First Name
Last Name
Email
example@example.com
What is your age?
Under 21
21-40
40 - 69
69+
Without my glasses and contacts... (check all that apply)
Farsightedness: I have trouble reading and seeing things up close
Nearsightedness: I have trouble driving and seeing things far away
Astigmatism: I have distorted vision and cannot see very well
How interested are you in being able to play sports or drive without glasses and contacts?
It's very important to me NOT to wear glasses for activities such as sports or driving.
It's not important to me. I do not mind wearing glasses.
What do you usually wear? (check all that apply)
Glasses
Contacts
Lenses
None
Do you have any of the following? (check all that apply)
Rheumatoid Arthritis
Multiple Sclerosis
Lupus
Cataracts
Keratoconus
Diabetic Retinopathy
Prior Eye Surgery
Prior serious eye injury
None
I would like to see well at a distance without relying on glasses and contact lenses.
Yes
No
Not Sure
Have you been told you have cataracts and require surgery?
Yes
No
I would like to see well up close without relying on glasses and contact lenses.
Yes
No
Not Sure
It is important to me to see well at night after cataract surgery.
Yes
No
Not Sure
Think about the things in life you want to do without depending on glasses after cataract surgery. Which group is the most important? (check all that apply)
Seeing Far Away (TV, night driving, golfing)
Seeing Intermediate Distances (Computer, cooking, iPad)
Seeing Close Up (Newsprint, maps, books)
Seeing Very Close (Embroidery, sewing and other crafting, puzzles)
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