Form Testing Page

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

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.

Can we text you?

Yes

No

Cataract Self Test New Form

1. How old are you?

2. Without my glasses and contacts... (check all that apply)

3. What do you usually wear? (check all that apply)

4. Do you have any of the following? (check all that apply)

5. Have you been told you have cataracts and require surgery?

Are the following statements important to you?

6. I would like to see well at a distance without relying on glasses and contact lenses.

7. I would like to see well up close without relying on glasses and contact lenses.

8. It is important to me to see well at night after cataract surgery.

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)

10. Would you like to speak with one of our specialists?