Please fill out and print this checklist, then bring it to your Consultation.
Without glasses or contact lenses…
|1. Do you have trouble seeing at distance?|
|2. Do you have trouble seeing up close?|
|3. Do you have night vision problems?|
|4. Do you have dry eye problems?|
|5. Are you pregnant or nursing?|
|6. Do you have severe diabetes or severe allergies?|
|7. Do you have any active eye diseases, for example |
glaucoma or cataracts?
|8. Do you have collagen vascular, autoimmune or |
immunodeficiency diseases (for example: Rheumatoid
arthritis, Lupus, AIDS)?
|9. Do you show signs of keratoconus (corneal disease)?|
|10. Do you have Vision Insurance? |
If yes, please provide Front Desk with Benefits card so
that we may make a copy.
|11. Would you be satisfied if your natural vision was greatly |
improved even if you still had to wear corrective lenses
some of the time?
|12. Do your glasses or contacts interfere with your |
|13. Do you feel that good vision without glasses is more |
important to you than perfect vision with glasses?
|14. Is it acceptable to you that you may need glasses for |
reading after LASIK?
|15. Do you have vision problems with reading or |
|16. Do you have vision issues, limitation, or restrictions with |
your work or profession?