Potential New Therapies Oculus Research Cary, North Carolina Age-Related Cataracts Pre-Screening Questionnaire Are you 50 years of age or older?(Required) Yes No Please specify DOB: DD/MM/YYY(Required)Have you been diagnosed by a doctor with Age-Related Cataracts?(Required) Yes No Not sure How would you rate your vision related to Age-Related Cataracts? (0=none, 10=most severe)(Required) No Vision Problems (0) Slight Vision Problems (1-4) Noticeable Vision Problems (5-7) Significant Vision Problems(8-10) Have you had cataract surgery?(Required) No Yes, Right Eye Only Yes, Left Eye Only Yes, Both Eyes Have you used any products or therapies listed below, including the following? - Contact Lenses(Required) Yes No Please specify item(s) and date(s) of last use:(Required)Have you had any eye procedures, surgeries, or injections within (Including, but not limited to: LASIK, refractive surgery, cataract surgery, etc.)(Required) Yes No Please specify what and when:(Required)Have all medications been stable for at least 30 days? (Including, but not limited to: diabetes with glycemia out of range, thyroid malfunction, etc.)(Required) Yes No Please specify:(Required)Do you have any significant or uncontrolled medical conditions that could affect study participation or safety?(Required) Yes No Not sure Please specify:(Required)Please specify:(Required)Your Name(Required) First Last Your Email Address(Required) Email Address Confirm Email Address Your Phone (for call or text)(Required)CAPTCHA CONTACT US
