1 What is your age group?

Under 18 19-39 40-59 60+

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2 Without my glasses and contacts... (Check All That Apply)

Without my glasses and contacts

Farsightedness : I have trouble reading and seeing things up close‎ Nearsightedness : I have trouble driving and seeing things far away‎ Astigmatism : I have distorted vision and cannot see very well‎

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3 What do you usually wear? (Check All That Apply)

What do you usually wear?

Glasses‎ Contacts‎ Reading Glasses‎ None of Them‎

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4 Do you have any of the following? (Check All That Apply)

Do you have any of the following?

Rheumatoid Arthritis‎ Multiple Sclerosis‎ Lupus‎ Cataracts‎ Keratoconus‎ Diabetic Retinopathy‎ Prior Eye Surgery‎ Prior serious eye injury‎ Are you pregnant or nursing?‎ None of the above‎

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5 I would like to see well at a distance without relying on glasses and contact lenses.

Rate this statement on a scale of 1 to 5 with 1 being the lowest.

I would like to see well at a distance without relying on glasses and contact lenses.

1 2 3 4 5

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6 I would like to see well up close without relying on glasses and contact lenses.

Rate this statement on a scale of 1 to 5, with 1 being the lowest.

I would like to see well up close without relying on glasses and contact lenses.

1 2 3 4 5

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7 Would your lifestyle improve if you were to become less dependent on glasses and contact lenses?

Would your career or business activities improve if you were to become less dependent on glasses and contacts?

Yes No

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