Self Test For Cataracts In Reading, PABerks Eye Physicians & Surgeons, Ltd. 1. What is your age group? Under 18 19-39 40-59 60+ 2. I am having trouble with: Painless blurring of vision Hazy, Cloudy vision Sensitivity to light and glare Double vision in one eye Poor night vision Fading or yellowing of colors Frequent changes in glasses or contact lens prescription 3. Have you been told you have cataracts? Yes No 4. What do you usually wear? Glasses Contacts Reading Glasses None of Them 5. Without my glasses and contacts...(check all that apply) Farsightedness: I have trouble reading and seeing things close up Nearsightedness: I have trouble driving and seeing things far away Astigmatism: I have distorted vision and cannot see very well 6. I would like to reduce or eliminate my need for spectacles or contact lenses: Yes No 7. Think about the things in life you want to do without 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) Name: * Email: * Phone: * If you think you might have cataracts, you may complete the following form and submit it to us. We will contact you to schedule a comprehensive cataract evaluation.