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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)

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Ocusun GCOS-H101-E06 Advertisement (3)

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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