Cataract Self-Test | Michigan Ophthalmology

Please select your age group: *

Under 45

45-49

50-59

60+

Which best describes your current vision? (Select all that apply)*

Myopia (near-sighted)

Hyperopia (far-sighted)

Astigmatism (distorted vision)

Presbyopia (need reading glasses or bifocals)

How are you currently correcting your vision? (Select all that apply)*

Single vision glasses

Bifocal or progressive glasses

Contact lenses

No correction

What are your current symptoms? (Select all that apply)*

Blurred or cloudy vision

Trouble seeing road signs

Dim or dark vision

Poor contrast sensitivity

Reduced perception of colors

Glare, halos, or starbursts

Trouble seeing at night or night driving

Difficulty reading

Grade your desire to see IN THE DISTANCE (driving, TV) without glasses after cataract surgery :

Grade your desire to see IN THE DISTANCE (driving, TV) without glasses after cataract surgery :*

Grade your desire to see INTERMEDIATE (computer range, car dashboard) without glasses after cataract surgery:

Grade your desire to see INTERMEDIATE (computer range, car dashboard) without glasses after cataract surgery:*

Grade your desire to see AT FUNCTIONAL NEAR (magazines, phone, menus) without glasses after cataract surgery:

Grade your desire to see AT FUNCTIONAL NEAR (magazines, phone, menus) without glasses after cataract surgery:*

Grade your desire to see ULTRA FINE PRINT (needlepoint, medication labels) without glasses after cataract surgery:

Grade your desire to see ULTRA FINE PRINT (needlepoint, medication labels) without glasses after cataract surgery:*

Are you familiar with monovision?

Are you familiar with monovision?*

Yes, and I liked it!

Yes, and I did not like it

Never heard of it or never tried it

Have you previously had refractive surgery (RK, PRK, LASIK)?

Have you previously had refractive surgery (RK, PRK, LASIK)?*

Yes

No

Which of the follow best describes your personality?*

Relaxed and easygoing

Detail-oriented, but can relax when needed

Organized planner

Perfectionist

Please list your occupation:*

How familiar are you with advanced technology solutions (Laser cataract surgery, Vivity IOL, PanOptix IOL, etc) for cataract surgery?

How familiar are you with advanced technology solutions (Laser cataract surgery, Vivity IOL, PanOptix IOL, etc) for cataract surgery?*

Other Comments:

Name*

First Last

Phone*

Email

Preferred method of communication:*

Phone call

Text message

Email

Do we have your permission to send you text messages?*

Yes

No, do not contact me by text message