Am I A Good CK Candidate

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

1. Do you have trouble with distance vision?

Yes No

2. Do you have trouble seeing up close?

Yes No

3. Do you wear reading glasses for close work?

Yes No

If yes, how many years have you been wearing them?

4. Do you have night vision problems?

Yes No

If yes, please describe:

5. Do you have dry eye problems?

Yes No

If yes, please describe:

6. Are certain sports or hobbies you're interested in compromised by your near vision?

Yes No

If yes, please describe:

7. Do you have severe diabetes or severe allergies?

Yes No

8. Do you have any active eye diseases, for example glaucoma or cataracts, or other health problems such as collagen, vascular, autoimmune or immunodeficiency diseases (for example: Rheumatoid arthritis, Lupus, AIDS)?

Yes No

9. Would you be satisfied with a procedure that allows you to function in daily life without reading glasses, but still requires you to use them for prolonged close work?

Yes No

10. What type of work do you do?

11. How many hours per day do you spend on the computer?

12. How many hours per day do you spend reading, either for business or for pleasure?

13. Describe any vision issues that occur when driving?