SELF EVALUATION QUESTIONNAIRE Determine Your Candidacy for LASIK NAME* PHONE*EMAIL* Do you wear contact lenses or glasses? Glasses Contact lenses Do you have trouble seeing far away or up close? Up close Far Away What is your age? Under 21 21 - 40 40 - 69 69+ Would your career or business activities improve if you were to become less dependent on glasses and contacts? Yes No Maybe How interested are you in being able to play sports without glasses and contacts? It’s very important to me NOT to wear glasses for activities such as sports. It’s not important to me. I do not mind wearing glasses. Are you interested in seeing well up close (reading) without glasses? It’s very important to me NOT to wear reading glasses. It’s not important to me. I do not mind wearing reading glasses to see things up close. Over 98% of LASIK patients see 20/40 or better after surgery. The results of LASIK laser vision correction have been tremendous for literally millions of people. Despite the amazing safety and results of this procedure there are associated risks. Are you willing to discuss these risks with our LASIK coordinator? Yes No
