Clone of Ocala Cataract Self-Evalutation

1

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

18-55

56+

2

Have you noticed any deterioration in your vision over the past 5 years?* This field is required.

Yes

No

3

Are you experiencing any of the following?* This field is required.(Check all that apply)

Blurry or cloudy vision

Halos and/or sensitivity to light

Poor night vision

Not as colorful or vibrant vision

Need brighter light for reading

None of the above

4

Without correction, do you have trouble seeing:* This field is required.Correction includes any eyeglasses or contact lenses.

Up Close

Far Away

Both

5

Do you have astigmatism?* This field is required.

Yes

No

Don't Know

6

What are your favorite hobbies or daily activities?

Reading, Sewing, Crafts, Knitting, Woodworking

Golfing, Watching TV, Hunting, Driving

Computer Work, Gardening, Cooking

Other

7

What is most important to you to have?* This field is required.(Check all that apply)

Good Distance Vision (Golfing, Watching TV, etc.)

Good Intermediate Vision (Gardening, Cooking, etc.)

Good Close Vision (Reading, Shaving, etc.)

All Vision Distances

8

If you have cataract surgery, how important is it to you to have more freedom from glasses afterwards?* This field is required.

Very Important

Not Important

Not Sure

9

If you could enjoy good vision for most activities without glasses, would you be able to tolerate some glare or halos at night?* This field is required.

YESNO

10

What is your full name?* This field is required.

First Name

Last Name

11

What is your email?* This field is required.

example@example.com

12

What is your mobile number?* This field is required.We will call you to discuss the options based on your quiz submissions.

Please enter a valid phone number.

13