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History of age-related cataracts? Take part in a study

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

Elderly patient meeting clinician on study flyer

958 Vandora Springs Rd.
Garner, NC 27529
(919) 346-6945
info@oculusresearch.com

9650 Brier Creek Pkwy Suite 103
Raleigh, NC 27617
(919) 346-6945
info@oculusresearch.com

940 SE Cary Pkwy Suite 100
Cary, NC 27518
(919) 346-6945
info@oculusresearch.com

Mon - Fri: 8:00 AM - 6:00 PM
Sat & Sun: Closed

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Myopia Control
Dry Eye
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Visual Disturbances in Dim Light
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