compasseyecare.com's LASIK Questionnaire
First Name     
Phone   (
)   -
 
Last Name   
Email  
 Do you wear ...?   Never   Sometimes   Frequently   Always   Score
  Glasses          
  Contact Lenses          
Do you need help seeing ...?   Never   Sometimes   Frequently   Always   Score
  Close up          
  Far away          
 Do you play sports with ...?   Never   Sometimes   Frequently   Always   Score
  Glasses          
  Contact Lenses          
 Do people say you look better ...?   Never   Sometimes   Frequently   Always   Score
  Without glasses          
 Would career/business activities improve with…?       Yes   No   Not Sure   Score
  Glasses            
  Contact Lenses            
  LASIK or other solution            
 My age is…?       Yes   No       Score
  Under 18                
  18 to 24                  
  25 to 34                  
  35 to 44                  
  45 to 54                  
  55 to 64                  
  Over 65                  
 Is it important to you that you are able to…?       Yes   No       Score
  Read without glasses              
  Read without Contact Lenses              
 If you are a LASIK candidate…?   Now   3-6 mths   6+ mths   Not Sure   Score
  How soon would you like to improve your lifestyle?          
 If your scored  10 or higher you may be a good candidate. Please call our office for an evaluation
Total