Am I a LASIK Candidate?

1. My name is:
   
   
2. My phone number is:
   
   
3. My e-mail address is:
   
   
4. What is your age?
   Under 18
   18 to 39
   40 to 59
   over 60
   
   
5. Has your prescription for glasses or contact lenses changed in the last 1 year?
   Yes   No
   
   
6. Do you have any medical eye conditions?
   Yes   No   Don't know
   
   
7. Do you have any of the following medical conditions: diabetes, autoimmune (e.g. lupus, rheumatoid arthritis) or immunodeficiency disease (e.g. AIDS)?
   Yes   No
   
   
8. Are you currently taking medications that may impair healing or with any ocular side effects?
   Yes   No   Don't know
   
   
9. Are you pregnant/nursing or expect to be soon?
   Yes   No
   
   
10. What type of vision problem do you have?
    Select One Nearsightedness (Myopia) - Difficulty seeing at distance Farsightedness (Hyperopia) - Difficulty seeing up close Astigmatism with/without Myopia or Hyperopia - All images are blurry
    
    
11. Do you wear reading glasses?
    Yes   No   Don't know
    
    
    
12. What is your main reason for considering vision correction?
    Select One Improve my lifestyle For my career My contact lenses are uncomfortable Eliminate my need for glasses or contact lenses
    
    
    
13. Have you been evaluated to determine if you are a candidate for LASIK surgery before?
    Yes   No
    
    
14. How soon would you like to have vision correction surgery?
    Select One Within the next one month 2-6 months Don't know

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