First Name
*
Last Name
*
Phone
*
Email
*
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What is your age group?
*
Under 18
19-39
40-59
60+
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Without my glasses and contacts...
Check all that apply
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What do you usually wear?
*
Glasses
Contacts
Reading Glasses
None of them
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Do you have any of the following
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Rheumatoid Arthritis
Multiple Sclerosis
Lupus
Cataracts
Keratoconus
Diabetic Retinopathy
Prior Eye Surgery
Prior serious eye injury
None of the above
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Have you been told you have cataracts and require surgery?
*
Yes
No
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Are the following statements important to you?
I would like to see well at a distance without relying on glasses and contact lenses.
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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.
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Yes
No
I'm not sure
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Think about the things in life you want to do without depending on glasses after cataract surgery. Which group is the most important?
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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)
Total Value
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