Laser Vision Correction Self Evaluation Test

Name(required)

Phone Number (required)

Email (required)

1. What is your age?
Under 2021-4041-5960 or greater

2. What kind of vision correction do you currently wear?
GlassesContactsBifocalsReading glasses only

3. If you wear contacts, do you wear?
Soft contactsToric soft contactsRigid Gas Permeable or Hard contact

4. Are you nearsighted or farsighted?
NearsightedFarsighted

5. Do you have astigmatism?
YesNo

6. Has your glasses prescription changed in the last 2 years?
YesNo

7. Have you ever been diagnosed with keratoconus, corneal problems or glaucoma?
YesNo

8. Do you have or have you ever been diagnosed with dry eyes?
YesNo

9. Do you have any health related conditions such as Diabetes, Lupus or Rheumatoid Arthritis?
YesNo