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