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Name:
Email:
1) Do you have difficulty driving at night?YesNo
2) Do you feel as though you are having difficulty seeing street signs/objects at a distance?YesNo
3) Does your vision seem blurry or dim?BlurryDim
4) Have you been experiencing problems with headlights while driving at night/glares/haloes?YesNo
5) When reading small print, do you need a brighter light to see?YesNo
6) Do you have double vision?YesNo