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Please Answer the Following Questions
About Your Health
(Note: Answering "yes" or "no" to these questions will not necessarily
indicate that you are not a candidate for Laser Vision Correction, so please
answer truthfully.)
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| 1. |
Yes
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No
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Do you have any uncontrolled medical problems? |
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| 2. |
Yes
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No
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Do you have diabetes (high blood sugar)? |
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| 3. |
Yes
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No
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Do you have any active autoimmune disorder or
collagen vascular disease such as rheumatoid arthritis, systemic lupus
erythematosis, polyarteritis nodosa, Wegener's Granulomatosis, or Sjögren's
Syndrome? |
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| 4. |
Yes
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No
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Do you have active or severe vascular disease? |
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| 5. |
Yes
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No
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Do you have an immune deficiency, autoimmune
disorder, AIDS, or HIV positive? |
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| 6. |
Yes
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No
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Are you taking any of these medications: Accutane,
Cordarone (Amiodarone), Imitrex, or more than 5mg of Prednisone? |
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| 7. |
Yes
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No
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Do you have a cardiac pacemaker? |
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| 8. |
Yes
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No
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Do you have to regularly take antihistamines? |
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| 9. |
Yes
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No
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Do you consider yourself to be generally healthy
? |
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Click Here to Proceed to the Next Page: Eye Health Information
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Click Here to Cancel the Screening and Start Over
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