IDEAL EYE SURGERY Cataract Self-Assessment 2-minute quiz to assess your cataract symptoms Step 1 of 8 12% Email Address(Required) Phone Number(Required)Name(Required) First Name Last Name Preferred Location (Optional)Select a locationSt. Louis - Main OfficeO'Fallon, ILSt. Louis, West countyAlton OfficeJerseyvilleShelbyvilleAvc Nashville OfficeMattoon - CharlestonEffinghamGreenvilleBreese OfficeBenton OfficeTaylorvilleLitchfield OfficePana Community HospitalCarlinvilleSte.Genevieve, MoSullivan, Mo Your Vision AssessmentPlease answer these questions honestly based on your current vision.Vision Clarity & QualityHow would you describe your overall vision right now?(Required) Clear and sharp Slightly cloudy or blurry Noticeably cloudy or dim Very cloudy, difficult to see clearly Has your vision gotten progressively worse over the past few months or years?(Required) No change Slightly worse Moderately worse Significantly worse Do you have difficulty seeing at night or in low light?(Required) No difficulty Some difficulty occasionally Yes, regularly have trouble Yes, I avoid driving at night because of it Light Sensitivity & GlareDo you see halos or glare around lights (especially at night)?(Required) No Occasionally Frequently All the time, very bothersome Are you more sensitive to bright lights than you used to be?(Required) No change Slightly more sensitive Moderately sensitive, need sunglasses often Very sensitive, bright light bothers me significantly Color & ContrastDo colors seem faded, dull, or yellowish?(Required) No, colors look normal Slightly less vibrant Noticeably faded or yellowish Yes, significant yellowing or dulling Do you have trouble distinguishing between similar colors?(Required) No difficulty Occasionally Often Yes, very difficult Reading & Close-Up WorkHas reading become more difficult?(Required) No change Need brighter light to read Words appear blurry even with good light Reading has become very challenging Do you find yourself holding reading material farther away or closer than before?(Required) No Yes, farther away Yes, closer I've had to stop reading small print Prescription ChangesHow often have you needed to change your eyeglass prescription in the past 2 years?(Required) No changes needed Once Twice Three or more times Does your vision seem blurry even with updated glasses or contacts?(Required) No, glasses/contacts work well Sometimes blurry despite new prescription Often blurry Yes, new prescriptions don't seem to help anymore Daily Activity ImpactWhich activities have become more difficult due to your vision? (Select all that apply) Driving (especially at night) Reading books/newspapers Watching TV Using computer/tablet Recognizing faces Reading street signs Cooking/detailed tasks Hobbies None of the above Do your vision problems interfere with your daily life or independence?(Required) Not at all Slightly, minor inconvenience Moderately, I've had to adjust some activities Significantly, I've stopped doing things I enjoy Medical History & Risk FactorsWhat is your age?(Required) Under 50 50-59 60-69 70 or older How long have you been experiencing vision changes?(Required) No significant changes Less than 6 months 6 months to 1 year 1-2 years More than 2 years Do any of these apply to you? (Check all that apply) Diabetes Current or former smoker High blood pressure Previous eye injury or surgery Prolonged sun exposure without sunglasses Family history of cataracts Long-term steroid use None of the above
