Home | Take the Test

Please answer the following questions about yourself and your eye condition, to determine whether you are likely to be eligible for refractive eye surgery.         Name:   Phone:   Email: < test results will be sent here

1) Do you have trouble seeing far away or up close or both?   Up close   Far away   Both   None

2) Do you wear contact lenses or glasses or both?   Contact lenses   Glasses   Both

3) If you wear contact lenses what type are they?   Soft or Disposable   Rigid gas permeable

4) Do you wear your glasses or contact lenses when you are looking?   Up close   Far away   Both

5) How long have your worn these contact lenses or glasses?   Years

6) When do you wear glasses or contacts?     When playing sports and water sports i wear Glasses Contacts None     When I read I wear Glasses Contacts None     When I drive I wear Glasses Contacts None     When I work I wear Glasses Contacts None

7) Has your spectacle prescription changed recently (select years) without change?   Yes No my last change was 1 2 3 4 5+ year/s ago.

8) What is your age?

9) What is your gender:   Male   Female     Are you Pregnant? Yes No     Are you Breast Feeding? Yes No

10) Do you have any of the following conditions?   Diabetes   Autoimmune disease (for example, AIDS, lupus, rheumatoid arthritis, multiple sclerosis, or myasthenia gravis)   Immunocompromised for any reason   Collagen vascular disease   Keloid scarring   I have none of these conditions

11) Are you currently taking medications Such as steroids or immunosuppressants, which can slow or prevent healing?   Yes   No

12) Do you have any of the following conditions?   Keratoconus or other corneal thinning disorder   Corneal scarring   Glaucoma   Cataracts   Ocular herpes diagnosed in past year   Retinal disease   Dry eye   I have none of these conditions

13) Which statements best reflects your primary reason for seeking LASIK? (You can select more then one answear)   I would like to get LASIK for career reasons.   I would like to get LASIK for lifestyle reasons.   I think I look better without glasses and do not like contact lenses.   I would like to reduce my dependence on glasses and/or contact lenses.   I would like to completely eliminate my need for glasses and/or contact lenses.

14) Before receiving LASIK Over 98% of LASIK patients see 6/12 or better after surgery. The results of LASIK laser vision correction have been tremendous for literally millions of people. Despite the amazing safety and results of this procedure there are associated risks. Are you willing to discuss these risks with our LASIK coordinator?   Yes   No

15) After receiving LASIK Would you be willing and able to comply with a schedule of medications and visits to your eye care professional for follow-up exams?   Yes   No