Cataract Self Test Form

Do you have any of the following? (Check All That Apply)*

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

Are the following statements important to you?

I would like to see well at a distance without relying on glasses and contact lenses.
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.
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.
It is important to me to see well at night after cataract surgery.*

YesNoI'm not sure

Below are four zones of vision. Consider things in your life that you want to do without dependence on glasses/contact lenses. Which is important to you? (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)‎

Are you ready to schedule a consultation?*

Yes, I'm ready to scheduleI want more informationNo, I'm not ready to schedule
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Please verify that you are human*
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