FREE LASIK SELF-EVALUATION

LASIK Self Evaluation

This short questionnaire is NOT a substitute for a proper medical examination and is simply a guide to help you work out if LASIK should be on your ‘to do’ list. The only way to know if LASIK is right for your eyes is to have a thorough LASIK Evaluation.

1. What is your age group? Required Question

	under 18
	21-40
	40-65
	65+

2. Do You Suffer From: Required Question

	Myopia (Nearsightedness)
	Hyperopia (Farsightedness)
	Both
	Astigmatism

3. Do You Usually Wear Glasses Or Contacts? Required Question

	Glasses
	Contacts
	Both

4. Do You Currently Require Reading Glasses? Required Question

	Yes
	No

5. Are You In Good General Health? Required Question

	Yes
	No

6. Have You Ever Had An Eye Injury Or Eye Surgery? Required Question

	Yes
	No

7. Have you ever been diagnosed with diabetic retinopathy, Keratoconus, Lupus or Rheumatoid Arthritis? Required Question

	Yes
	No

8. What is your main expectation from having LASIK? Required Question

	A positive impact on my lifestyle (better appearance, freedom to play sports, etc)
	Better vision in general

9. Please provide us with your contact information:

First Name Required Question

Last Name

Email Address Required Question

Phone Number Required Question