Schein Ernst Mishra Eye Cataract Self-Evaluation

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Schein Ernst Mishra Eye Cataract Self-Evaluation

Welcome to our Cataract Self-Evaluation. This short questionnaire is a first step in determining if cataracts may be affecting your vision. Start by clicking here.

11Questions

1
Select your age group* This field is required.
Under 18
19-39
40-59
60+
2
Were your first glasses more for reading or distance?* This field is required.
Distance
Reading
3
Have you noticed any deterioration of your vision in the past 5 years?* This field is required.
YESNO
4
Without my glasses and contacts:* This field is required.
I have trouble reading and seeing things up close
I have trouble driving and seeing things that are far away
I've been told that I have astigmatism
5
What do you usually wear?* This field is required.
Glasses
Contacts
Reading Glasses
6
Describe your vision* This field is required.Select all that apply
Blurry or cloudy
Not as colorful or vibrant as it used to be
Halos around lights and/or over-sensitivity to light
Poor at night
Double or multiple images in one eye
None of the above
7
Can we get your name?* This field is required.
First Name
Last Name
8
Phone Number* This field is required.
Area Code
Phone Number
9
Email* This field is required.
example@example.com
10
I consent to receiving email communications* This field is required.
YESNO
11
Please verify that you are human* This field is required.
Should be Empty:

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