Please fill out then print this checklist, and bring it with you for 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: