1. What is your current age?
   Under 18
   18 to 40
   41 to 55
   over 55
   
   
2. Has your prescription for glasses or contact lenses changed in the last 2 years?
   Yes  No
   
   
3. Do you have any of the following eye conditions: thin corneas, corneal scarring, glaucoma, cataracts, retinal disease?
   Yes  No  Don't know
   
   
4. Do you have any of the following medical conditions: uncontrolled diabetes or a collagen vascular, autoimmune (e.g. lupus, multiple sclerosis, rheumatoid arthritis) or immunodeficiency disease (e.g. AIDS)?
   Yes  No
   
   
5. Are you currently taking medications that may impair healing (e.g. steroids), or medications with ocular side effects (e.g. Accutane or Cordarone)
   Yes  No  Don't know
   
   
6. Are you pregnant or nursing?
   Yes  No
   
   
7. What type of vision problem do you have?
   Select One Difficulty seeing distance - Nearsightedness (don't know prescription) Difficulty seeing up close - Farsightedness (don't know prescription a) Nearsightedness and mild prescription (less than -3 D) Nearsightedness and moderate prescription (-3 to -6 D) Nearsightedness and severe prescription (greater than -6 D) Farsightedness and moderate prescription (less than +2 D) Farsightedness and severe prescription (+2 to +6 D) Farsightedness and extreme prescription (greater than +6 D)
   
   
8. Do you wear reading glasses or bifocals/trifocals?
   Yes  No  Don't know
   
   
9. Do you have astigmatism greater than 6 D?
   Yes  No  Don't know
   
   
10. What is your primary reason for considering LASIK?
    Select One Improve my lifestyle (e.g. sports, recreational activities) For my career (e.g. Firefighter, police officer) No longer tolerating contact lenses I look better without glasses I want to completely eliminate my need for glasses or contact lenses
    
    if any other reason, then please specify.
    
    
    
11. Have you made the decision to have laser eye surgery?
    Yes  No
    
    
12. How soon would you like to have corrective laser eye surgery?
    Select One Next month or so 3-6 months Don't know
    
    
13. Are you scarred of Laser ? Why?
    
    
    
14. What's your budget for the surgery ?
    

Personal Details