Click on the appropriate answer:
Do you have a history of using steroid or steroid drops for prolonged periods?	Yes No
Do you recall needing frequent prescription changes for your glasses in the past or present?	Yes No
Do you eat less than seven to nine servings of fruits and vegetables daily?	Yes No
Do you weight 20% more today than when you graduated from high school?	Yes No
Do you or have you ever spent considerable time around water, sand, or snow?	Yes No
Do you have difficulty reading small fine print even with your reading glasses?	Yes No
Do you remember having a severe blow or trauma to the eye?	Yes No
Do you notice night vision gradually diminishing?	Yes No
Do you have trouble distinguishing between colors?	Yes No
Do you have more trouble reading street signs at night?	Yes No
Do you notice your television isn't as sharp as it used to be?	Yes No
Do you have a history of chronic diuretics usage?	Yes No
Do you have a history of tranquilizer usage?	Yes No
Do you drink more than two alcoholic beverages a day?	Yes No
Do you seldom wear UV protective sunglasses outdoors?	Yes No
Do any members of your family have a cataract?	Yes No
Do you realize that you are over 60 years of age?	Yes No
Do you have diabetes mellitus?	Yes No
Do you or have you ever smoked for more than a year?	Yes No
Do you notice halos around lights at night?	Yes No
Do you have a history of high blood pressure?	Yes No
Do you have a history of high cholesterol?	Yes No
Do you take vitamin C & vitamin E daily?	Yes No
Do you live at high altitude?	Yes No

 

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