Lasik Self Evaluation Test

Do you have trouble seeing far away or up close?

Up close

Far away

Both

How interested are you in being able to play sports without glasses and contacts?

It's very important to me NOT to wear glasses for activities such as sports.

It's somewhat important to me not to wear glasses for certain activities.

It's not important to me. I do not mind wearing glasses.

What is your age?

Under 21

21 - 30

31 - 40

41 - 50

51 - 60

61 - 70

71 - 80

81 or older

Are you interested in seeing well up close (reading) without glasses?

It's very important to me NOT to wear reading glasses.

It's not important to me. I do not mind wearing reading glasses to see things up close.

Do you currently use corrective lenses?

Glasses

Contact lenses

Both

Reading Glasses Only

Would your career or business activities improve if you were to become less dependent on glasses and contacts?

Yes

No

Maybe

The results of LASIK laser vision correction have been tremendous for millions of people. Many LASIK patients see 20/40 or better after surgery. Despite continuous improvements in technology and safe and effective results, there are associated risks with the procedure. Would you like to discuss these risks and any other questions with our Kansas City LASIK team?

Yes

No

What method is best to contact you?

Phone

Email

Name:
Phone:
E-Mail:
How did you hear about us?
If other, please explain: