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CATARACT SYMPTOM QUIZ
Is it time for a cataract surgery evaluation?
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1
Do you have difficulty driving at night?
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Yes
No
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2
Are distant objects more difficult for you to see?
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Yes
No
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3
Does your vision seem blurry or dim?
*
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Yes
No
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4
Have colors become less vibrant?
*
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Yes
No
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5
Are your eyes more light sensitive than they used to be?
*
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Yes
No
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6
When you are looking at a light, do you see a halo around it?
*
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Yes
No
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7
Do you need a brighter light to see when reading small print?
*
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Yes
No
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8
Do you have double vision?
*
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Yes
No
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9
What age range are you in?
*
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18-35
36-54
55+
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10
Name
*
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First Name
Middle Name
Last Name
Suffix (Jr, Sr, III, ect)
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11
Date of Birth
*
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-
DOB
Year
Month
Day
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12
Phone Number
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Area Code
Phone Number
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13
E-Mail
Confirm E-mail
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