Do you struggle with any of the following?

Reading small print, such as labels on medicine bottle, a telephone book, food labels, the newspaper, or a book? ---NoA littleA moderate amountA great dealUnable to do the activity

Reading a large-print book or large-print newspaper or numbers on a telephone? ---NoA littleA moderate amountA great dealUnable to do the activity

Recognizing people when they are close to you? ---NoA littleA moderate amountA great dealUnable to do the activity

Seeing steps, stairs, or curbs? ---NoA littleA moderate amountA great dealUnable to do the activity

Reading traffic signs, street signs, or store signs? ---NoA littleA moderate amountA great dealUnable to do the activity

Doing fine handwork like sewing, knitting, crocheting, or carpentry? ---NoA littleA moderate amountA great dealUnable to do the activity

Writing checks or filling out forms? ---NoA littleA moderate amountA great dealUnable to do the activity

Playing games such as bingo, dominos, card games, mahjong? ---NoA littleA moderate amountA great dealUnable to do the activity

Taking part in sports like bowling, tennis, handball or golf? ---NoA littleA moderate amountA great dealUnable to do the activity

Cooking? ---NoA littleA moderate amountA great dealUnable to do the activity

Watching television? ---NoA littleA moderate amountA great dealUnable to do the activity

Do you currently drive a car? ---YesNo

I authorize a Switch Eye Center representative to contact me to discuss the results of my Cataracts Self-Test. I acknowledge that the information provided in this questionnaire will be used to send additional information about offers related to our services.

Yes, I authorize * authorize

Your Name (required)

Your Phone (required)

Your Email(required)

Your Zip Code(required)