Cataract Self Test

Have you been diagnosed with cataracts?

Yes No

What is your age group?

45-50 50-60 Over 60

Do you have any health problems that make it risky for you to have cataract surgery?

Yes No

Do you need good vision for activities like reading, driving, or playing sports?

Yes No

Do you have any other eye problems that might affect how well you can see after cataract surgery?

Yes No

Do you have a clear idea of what you can expect from cataract surgery and the lenses you might choose?

Yes No

Great. Who should we send the results to?

Your Title

Your Name:

(Optional) If you would like us to call you with more information, please insert your number below:

How did you hear about us?