Cataract Self Test Form

First Name*
Last Name*
Phone*
Email*
Do we have consent to text you?*

What is your age group?*

Without my glasses and contacts... (Check All That Apply)*

What do you usually wear? (Check All That Apply)*

Rheumatoid Arthritis‎Multiple Sclerosis‎Lupus‎Cataracts‎Keratoconus‎Diabetic Retinopathy‎Prior Eye Surgery‎Prior serious eye injury‎None of the above‎

YesNo

Are the following statements important to you?

I would like to see well at a distance without relying on glasses and contact lenses.
YesNoI'm not sure
I would like to see well up close without relying on glasses and contact lenses.
YesNoI'm not sure
It is important to me to see well at night after cataract surgery.
YesNoI'm not sure

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)‎

Yes, I'm ready to scheduleI want more informationNo, I'm not ready to schedule
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