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Are you experiencing?
- Clouded, blurred, or dim vision?
- Difficulty seeing distant objects?
- Sensitivity to light or glare?
- Difficulty seeing distant objects?
- Seeing a halo around lights?
- Fading or yellowing of colors?
Has your prescription for eyeglasses changed more often than usual?
- Yes
- No
Do you need brighter light for reading?
- Yes
- No
Does your vision sometimes seem distorted?
- Yes
- No
Have you experienced double vision in one eye only?
- Yes
- No
Do you see “ghost” images?
- Yes
- No
How do you prefer to have a member of our clinic’s staff follow up and contact you?
- Phone
- Email

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