LASIK QUESTIONNAIRE

DO YOU WEAR VISION CORRECTION?

WHAT TYPE OF CORRECTION DO YOU WEAR?

I am nearsighted (I see better at near than distance without glasses I am farsighted ( I see better at distance than near without glasses I have astigmatism only I have nearsightedness and astigmatism I have farsightedness and astigmatism I have no presciption I am unsure

DO YOU HAVE ANY OF THE FOLLOWING?

I have been told by my eye doctor that I have cataracts I have had prior eye surgery I have had prior eye infection or ulcer that affected my vision I have had a prior eye injury that affected my vision I have a medical condition that has affected my eyes or vision I am currently pregnant or nursing and my vision has changed None of the above

HOW STRONG IS YOUR EYE GLASS OR CONTACT LENS PRESCRIPTION?

I am nearsighted less than or equal to -6 diopters I am farsighted less than or equal to +5 diopters I am nearsighted more -6 diopters I am farsighted more than +5 diopters I have astigmatism less than 5 diopters I have astigmatism more than 5 diopters I don't know my prescription level I only use glasses for reading and am older than 40

Your Contact Information

Full Name

Phone/Text

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