Self-Evaluation for LASIK


Self-Evaluation LASIK


LaserVue Eye Center offers a full range of vision correction options for our San Francisco, San Jose, Santa Rosa, Walnut Creek and SF Bay Area LASIK patients. We choose the optimum vision correction procedure or solution to suit individual needs beyond LASIK. To help you learn if you might be a good candidate for LASIK or another procedure, please complete the form below and our vision correction coordinator will contact you to discuss the next step.

For best results, please fill out this test completely

Those marked with * are required for a response.

This short questionnaire is NOT a substitute for a proper medical examination and is simply a guide to help you work out if LASIK should be on your ‘to do’ list. The only way to know if LASIK is right for your eyes is to have a thorough LASIK Evaluation.

What Is Your Age Group?

 under 18 18 - 40 40 - 65 over 65

Do You Suffer From:

 Myopia (Nearsightedness) Hyperopia (Farsightedness) Both Astigmatism

Do You Usually Wear Glasses Or Contacts?

 Glasses Contacts Both

Do You Currently Require Reading Glasses?

 Yes No

Are You In Good General Health?

 Yes No

Have You Ever Had An Eye Injury Or Eye Surgery?

 Yes No

What Is Your Main Expectation From Having Custom Laser Vision Correction?

 A positive impact on my lifestyle (better appearance, freedom to play sports, etc) Better vision in general

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