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Binh Q. Nguyen, MD
Owen L. Qi, MD
Rana S. Torabi, MD
Celina N. Lewis, OD
Natalia A. Chramiec, OD
Zakariah Mikos, O.D.
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Cataract Self-Test
Home
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Cataract Surgery With Lifestyle Lenses
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Cataract Self-Test
Step
1
of
9
11%
1. How old are you?
Under 18
19-39
40-59
60+
2. Without my glasses and contacts… (check all that apply)
Farsightedness: I have trouble reading and seeing things up close
Nearsightedness: I have trouble driving and seeing things far away
Astigmatism: I have distorted vision and cannot see very well
3. What do you usually wear? (check all that apply)
Glasses
Contacts
Reading Glasses
None of Them
4. Do you have any of the following? (check all that apply)
Rheumatoid Arthritis
Multiple Sclerosis
Lupus
Cataracts
Keratoconus
Diabetic Retinopathy
Prior Eye Surgery
Prior serious eye injury
None of the above
Rheumatoid Arthritis
Cataracts
Prior Eye Surgery
Multiple Sclerosis
Keratoconus
Prior serious eye injury
Lupus
Diabetic Retinopathy
None of the above
5. Have you been told you have cataracts and require surgery?
Yes
No
Are the following statements important to you?
6. I would like to see well at a distance without relying on glasses and contact lenses.
Yes
No
I’m not sure
7. I would like to see well up close without relying on glasses and contact lenses.
Yes
No
I’m not sure
8. It is important to me to see well at night after cataract surgery.
Yes
No
I’m not sure
9. Think about the things in life you want to do without depending on glasses after cataract surgery. Which group is the most important? (check all that apply)
Seeing Far Away (TV, night driving, golfing)
Seeing Intermediate Distances (Computer, cooking, iPad)
Seeing Close Up (Newsprint, maps, books)
Seeing Very Close (Embroidery, sewing and other crafting, puzzles)
10. Would you like to speak with one of our specialists?
I’m ready to book my consultation!
Yes, please call me to discuss my options.
I’m not ready yet.
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Last Name*
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