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Please Answer the Following Questions
About Your Eye 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 |
No |
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Has your glasses or contact lens prescription been
stable (not changing) over the past year? |
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| 2. |
Yes |
No |
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Have you ever been told that you have a corneal
condition called keratoconus, "forme
fruste keratoconus", or any suspicion that you may have keratoconus ? |
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| 3. |
Yes |
No |
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Have you ever had any condition leading to
scarring of the cornea? |
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| 4. |
Yes |
No |
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Have you ever had a corneal infection caused by
herpes simplex or herpes zoster (shingles)? |
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| 5. |
Yes |
No |
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Do you have a problem with the eyes being severely
dry? |
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| 6. |
Yes |
No |
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Have you ever had a problem with recurrent corneal
erosions caused by a corneal epithelial dystrophy such as a "basement membrane
dystrophy" or "map-dot-fingerprint dystrophy"? |
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| 7. |
Yes |
No |
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Do you experience excessive scar formation such as
keloid formation? |
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| 8. |
Yes |
No |
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Do you have corneal swelling (edema) or a "corneal
endothelial dystrophy" such as "Fuchs Dystrophy"? |
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| 9. |
Yes |
No |
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Have you ever been told that your corneal was
abnormally thin or irregular in curvature? |
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| 10. |
Yes |
No |
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Do you have glaucoma (elevated eye pressure) or a
history of responding to steroid use with an increase in eye pressure? |
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| 11. |
Yes |
No |
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Do you have any ocular condition such as cataract,
uveitis (internal ocular inflammation), diabetic retinopathy, amblyopia (lazy
eye), a history of prior eye surgery, or eye muscle imbalance / misalignment ? |
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| 12. |
Yes |
No |
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Do you have any history of retinal tears,
detachment, floaters, or seeing flashing lights? |
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Click Here to Proceed to the Next Page: Lasik Information
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Click Here to Cancel the Screening and Start Over
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