CATARACT SCREENING REQUEST FORM

District *

Block Name *

PHC Name *

Beneficiary Name *

Age/Gender *

Beneficiary Mobile No *

Guardian Name *

Guardian Mobile No *

Not able to count fingers correctly from the distance of 6 meter or 20 feet in daylight *

Both Eyes

Right Eye

Left Eye

Are you taking any medicine for *

High Blood Pressure

High Blood Sugar

Heart Problem