Self Test For Cataracts Reading, PA

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.