Please fill out then print this checklist, and bring it with you for your Consultation.

Without glasses or contact lenses…

				Yes		No
		1. Do you have trouble seeing at distance?
		2. Do you have trouble seeing up close?
		3. Do you have night vision problems?
		If yes, please describe:
		4. Do you have dry eye problems?
		If yes, please describe:
		5. Are you pregnant or nursing?
		6. Do you have severe diabetes or severe allergies?
		7. Do you have any active eye diseases, for example glaucoma or cataracts?
		8. Do you have collagen vascular, autoimmune or immunodeficiency diseases (for example: Rheumatoid arthritis, Lupus, AIDS)?
		9. Do you show signs of keratoconus (corneal disease)?
		10. Do you have Vision Insurance?       If yes, please provide Front Desk with Benefits card so       that we may make a copy.
		11. Would you be satisfied if your natural vision was greatly improved even if you still had to wear corrective lenses some of the time?
		12. Do your glasses or contacts interfere with your recreational activities?
		If yes, which activities:
		13. Do you feel that good vision without glasses is more important to you than perfect vision with glasses?
		14. Is it acceptable to you that you may need glasses for reading after LASIK?
		15. Do you have vision problems with reading or computer work?
		If yes, please describe:
		16. Do you have vision issues, limitation, or restrictions with your work or profession?
		If yes, please describe: