Laser Vision Correction Screening Evaluation
CustomVue™  Lasik

 


Vision Information
(If you do not have a copy of your glasses or contact lens prescription)

Answer the following questions about your vision.  If you have a copy of a recent glasses prescription, click here.  If you have a recent
contact lens prescription, click here.)

Which of the following best describes your distance vision, and how you correct your distance vision.  This includes tasks such as driving and watching TV.
 
I can see well at distance without glasses or contact lenses.
 
Without glasses or contact lenses my distance vision is poor.
 
Without glasses or contact lenses my distance vision is fair, but in situations such as driving at night, my vision is much better with glasses or contacts.
 

 


Which of the following best describes how you correct your near vision, such as reading the newspaper, doing close hand work, or using a computer?
 
I can see well at near with or without glasses or contact lenses, and the glasses or contacts are neither bifocal nor monovision.
 
To see well at near I need to use bifocals, trifocals, or separate reading glasses.
 
While I usually remove my glasses or contacts to see at near, but I can read with them on also.
 
I cannot see at near without removing my glasses or contact lenses.
 
I usually wear contact lenses, and they are either monovision or bifocal lenses.
 

Click Here to Proceed to the Next Page: Medical Information   

 

Click Here to Cancel the Screening and Start Over

 

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Barry E. Roper, M.D.      D. Alan Chandler, M.D.      Malcolm Magovern, M.D.
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