Cataract Evaluation Please answer the following questions so we can better serve you. Name* DOB*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Email* Enter Email Confirm Email Have you ever been told you have cataracts? Yes No Have you ever had cataract surgery? Yes No Symptoms Have you ever experienced: Poor night vision? Yes No Seeing rings or halos around lights? Yes No Glare caused by headlights or bright sunlight? Yes No Hazy and/or blurry vision? Yes No Problems seeing in poor or dim light? Yes No A hassle when it comes to glasses/contact lenses? Yes No Cataract surgery can be safely postponed until you feel you need better vision. If stronger glasses will not improve your vision, and if the only way to see better is cataract surgery, then do you feel your vision problem is bad enough to require cataract surgery now? Yes No Additional Questions/Concerns:Please confirm you are not a robot. Please send me additional information on cataracts.
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