LASIK Evaluation Quiz

Name:	*
Phone:	*
E-Mail:

Do you wear glasses or contact lenses?
Glasses
Contact Lenses
Both

Are you in good general health?
Yes
No

What is your age?

Have you ever had eye surgery?
Yes
No

Have you ever had any eye injuries or diseases?
Yes
No

Which of the following conditions do you have (select all that apply)?
Myopia (Nearsightedness)
Hyperopia (Farsightedness)
Astigmatism

How well do you see at night?
Very Well
OK, but could be better
Poorly

Do you use reading glasses or bifocals?
Yes
No

Which is the most important issue for you regarding LASIK?
Affordability
Safety
Experience of doctor
Being free of my glasses or contacts

Do you know what is involved in a LASIK procedure?
Yes
Possibly
No

Are you concerned that the risks outweight the benefits of LASIK?
Yes
Possibly
No

Have you ever had a LASIK evaluation before?
Yes
No