:: Brint Custom Vision :: About Lasik :: Am I a Good Lasik Candidate? ::

Please fill out then print this checklist, and bring it with you for your Consultation.

Health Checklist

Yes

1. Do you have trouble seeing at distance?

2. Do you have trouble seeing up close?

3. Do you have astigmatism?

4. Are you at least 18 years old?

5. Has your vision been stable for 1 year?

6. Do you have night vision problems?

If yes, please describe:

7. Do you have dry eye problems?

If yes, please describe:

8. Are you pregnant or nursing?

9. Do you have severe diabetes or severe allergies?

10. Do you have any active eye diseases, for example glaucoma or cataracts?

11. Do you have collagen vascular, autoimmune or immunodeficiency diseases (for example: Rheumatoid arthritis, Lupus, AIDS)?

Lifestyle Checklist

Yes

1. Do your glasses or contacts often prevent you from enjoying everyday living?

2. Would you be satisfied if your natural vision was greatly improved even if you still had to wear corrective lenses some of the time?

3. Do you fear that you would be totally disabled if you lost/misplaced your glasses or contact lenses?

4. Do you feel that your appearance is better without glasses?

5. Do your glasses or contacts interfere with your recreational activities?

If yes, which activities:

6. Do you consider yourself to be an easy-going person and adaptable to change?

7. Do you feel that good vision without glasses is more important to you than perfect vision with glasses?

8. Is it acceptable to you that you may need glasses for reading after LASIK?

9. Do you have vision problems with reading or computer work?

If yes, please describe:

10. Do you have vision issues, limitation, or restrictions with your work or profession?

If yes, please describe: