Schein Ernst Mishra Eye Cataract Self-Evaluation

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.