CATARACT SYMPTOM QUIZ

1

Do you have difficulty driving at night?* This field is required.

Yes

No

2

Are distant objects more difficult for you to see?* This field is required.

Yes

No

3

Does your vision seem blurry or dim?* This field is required.

Yes

No

4

Have colors become less vibrant?* This field is required.

Yes

No

5

Are your eyes more light sensitive than they used to be?* This field is required.

Yes

No

6

When you are looking at a light, do you see a halo around it?* This field is required.

Yes

No

7

Do you need a brighter light to see when reading small print?* This field is required.

Yes

No

8

Do you have double vision?* This field is required.

Yes

No

9

What age range are you in?* This field is required.

18-35

36-54

55+

10

Name* This field is required.

First Name

Middle Name

Last Name

Suffix (Jr, Sr, III, ect)

11

Date of Birth

DOB

12

Phone Number* This field is required.

Area Code

Phone Number

13

E-Mail

Confirm E-mail