Am I A Good Candidate?

Please fill out then print this checklist, and bring it with you for your Consultation.

Health Checklist

1. Do you have trouble seeing at distance?

Yes No

2. Do you have trouble seeing up close?

Yes No

3. Do you have astigmatism?

Yes No

4. Are you at least 18 years old?

Yes No

5. Has your vision been stable for 1 year?

Yes No

6. Do you have night vision problems?

Yes No

If yes, please describe:

7. Do you have dry eye problems?

Yes No

If yes, please describe:

8. Are you pregnant or nursing?

Yes No

9. Do you have severe diabetes or severe allergies?

Yes No

10. Do you have any active eye diseases,
for example glaucoma or cataracts?

Yes No

11. Do you have collagen vascular, autoimmune
or immunodeficiency diseases
(for example: Rheumatoid arthritis, Lupus, AIDS)?

Yes No

Lifestyle Checklist

1. Do your glasses or contacts often prevent you from
enjoying everyday living?

Yes No

2. Would you be satisfied if your natural vision
was greatly improved even if you still had to
wear corrective lenses some of the time?

Yes No

3. Do you fear that you would be totally disabled if you
lost/misplaced your glasses or contact lenses?

Yes No

4. Do you feel that your appearance
is better without glasses?

Yes No

5. Do your glasses or contacts interfere with
your recreational activities?

Yes No

If yes, which activities:

6. Do you consider yourself to be an easy-going person
and adaptable to change?

Yes No

7. Do you feel that good vision without glasses
is more important to you than perfect vision with glasses?

Yes No

8. Is it acceptable to you that you may need glasses
for reading after LASIK?

Yes No

9. Do you have vision problems with reading
or computer work?

Yes No

If yes, please describe:

10. Do you have vision issues, limitation, or restrictions
with your work or profession?

Yes No

If yes, please describe: