LASIK Self Evaluation Name* Phone* Email* Do you have trouble seeing far away or up close? Far away Up close Both Do you wear glasses or contact lenses? Glasses Contact lenses Neither Has your prescription for glasses or contact lenses stayed the same for at least a year? Yes No Not Sure How interested are you in being able to play sports without glasses or contact lenses? It’s very important to me NOT to wear glasses or contact lenses for activities such as sports. It’s not important to me. I do not mind wearing glasses or contact lenses. 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. Would your career or business activities improve if you were to become less dependent on glasses or contact lenses? Yes No Maybe What is your age? Under 21 21 – 40 40 – 69 69+ The results of LASIK laser vision correction are generally excellent, with over 98% of patients see 20/40 or better after surgery. Despite the amazing safety and results of this procedure, there are associated risks. Are you willing to discuss these risks the doctor and our LASIK coordinator? Yes No Name This field is for validation purposes and should be left unchanged.