Please fill out and print this checklist, then bring it to your Consultation.

Without glasses or contact lenses…

Yes  No
1. Do you have trouble seeing at distance?
2. Do you have trouble seeing up close?
3. Do you have night vision problems?
If yes, please describe:
4. Do you have dry eye problems?
If yes, please describe:
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
recreational activities?
If yes, which activities:
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
computer work?
If yes, please describe:
16. Do you have vision issues, limitation, or restrictions with
your work or profession?
If yes, please describe: