Eyecare Test I SSM Health

Do you ever experience cloudy or blurred vision? *

Yes

No

Do you notice difficulties reading, driving, watching TV or performing other daily activities? *

Yes

No

Are lights (light bulbs or lamps) too bright or giving off a glare or halo? *

Yes

No

Do you need to increase your contact or eyeglass strength regularly? *

Yes

No

Do you have trouble seeing or driving at night? *

Yes

No

Are you concerned about changes in your vision affecting your balance? *

Yes

No

Are colors less vibrant and crisp? *

Yes

No

Are you experiencing distortion in either your right or left eye? *

Yes

No

First Name *

Last Name *

Address *

Address 2

City *

State *

ZIP *

Phone

Enter in the following format 123-123-1234 or 1234567890

Email Address *

I have read the Notice of Privacy Practices. *

address3

Do You Have Cataracts?