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Blurry or cloudy
Not as colorful and vibrant as it used to be
Halos around lights and/or over-sensitivity to light
Poor vision at night
Double or multiple images in one eye
None of the above
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Yes
No
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Read newsprint and books
Computer work
Watch TV and/or movies
Driving during daylight hours
Driving at night
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Name
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Phone Number
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Which option describes your vision BEST?
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Do you have difficulty seeing street signs, curbs, freeway exits, and/or traffic lights while driving?
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Do you have difficulty with leisure activities such as sports or hobbies? (I.e., playing card games, bingo, dominos or sports such as bowling, hunting, golf, tennis or other)
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Do you have difficulty reading books and newspapers even with good light, extra blinking and proper glasses?
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What is MOST important for you to be able to do WITHOUT glasses?
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I would like to be contacted by Fry Eye Associates to schedule an evaluation for Cataracts.
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