LASIK Eligibility Self-Assessment Questionnaire
Complete this self-assessment to review basic LASIK eligibility factors. This form is for screening only and does not replace a professional eye examination.
Eligibility Basics
Age
*
Current vision correction type
*
Glasses
Soft contact lenses
Rigid gas permeable lenses
None
Other
How long has your vision prescription been stable?
*
Please Select
Less than 6 months
6–11 months
1–2 years
More than 2 years
Not sure
Are you seeking LASIK for
*
One eye
Both eyes
Eye Health and Treatment History
Have you had any prior eye surgery or eye procedures?
*
Yes
No
If yes, please provide details
Which of the following eye conditions have you had or been diagnosed with?
Dry eye
Corneal disease
Keratoconus
Glaucoma
Cataracts
None of the above
Other eye condition
Do you currently use any eye drops or eye medications?
*
Yes
No
If yes, please list the eye drops or eye medications and how often you use them
Which best describes your current contact lens wear habits?
*
Daily
Occasional
Extended wear
Not currently wearing contacts
General Health and Screening Factors
Are you currently pregnant or breastfeeding?
*
No
Yes
Not applicable
Do you have any general health conditions that may affect healing or LASIK candidacy?
*
Autoimmune disease
Diabetes
Uncontrolled allergies
Dry eye syndrome
Hormonal changes
None of these
What is your main reason for seeking LASIK or your primary visual concern?
*
Submit
Should be Empty: