Refractive Surgery Consultation Form
Full Name
Procedure
LASIK
CK
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone Number
Work Phone Number
Other (cell)
Emergency Name/Number
Home Email Address
example@example.com
Age
Date of Birth
-
Month
-
Day
Year
Date
Sex
Occupation
Employer
Routine Optometrist/Ophthalmologist
Family Physician
Medical Insurance
Do You Wear Glasses?
Yes
No
What Kind?
Near
Distance
Both
Contact Lenses?
Hard
Soft
GP
None
Last Worn?
How Did You Hear About Us?
If you are a good candidate for Vision Correction, how soon would you like to have the procedure?
What has motivated you to consider Vision Correction?
The least I expect from Vision Correction is (select all that apply)
See better using thinner glasses
See without glasses for routine tasks
Pass a drivers test
Meet job qualifications
Do you have any other objectives or expectations from having the procedure?
Do you have any challenges with your night vision while wearing your glasses or contacts?
Yes
No
Have you or do you intend to visit any other Laser Eye Centers or Doctors?
Yes
No
Which one?
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Medical History
Please check if you have any of the following conditions:
Diabetes
Pregnant/Nursing or planning on becoming pregnant in the next 3 months
Rheumatoid Arthritis
Pacemaker
Psychiatric/Psychological Therapy/Depression
Drug Allergies
Taken Amiodarone (Cordarone, Pacerone)?
Take Acutane (oral acne medication) within the last year?
If yes to drug allergies, what are you allergic to?
If yes to acutane, when did you stop taking it?
Any other existing medical problems?
List medications you are currently taking
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Ocular History
Please check if you have any of the following conditions
Past or present problems with contacts
Ocular Infections? (Specifically Ocular Herpes)
Previous Eye Surgery
History of eye trauma
Glaucoma
Cataracts
Retina Problems
Eyes Muscle Problems or history or eye muscle surgery
Corneal erosion syndrome (from a prior corneal abrasion)
Been told you are not a candidate for Laser Eye Surgery
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Pre-Operative Evaluation
Check all that apply
Has your prescription changed significantly in the last year?
Over 40 years of age?
Had good vision all your life, until age 40?
Dislike wearing or dealing with glasses?
Remove your glasses to read?
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Dry Eye Checklist
Please check off any symptoms you have experienced with or without contact lenses
Dry sensation
Stinging
Mucous discharge
Solution sensitivity
Light sensitivity
Lens discomfort
Scratchy, gritty feeling
Lid infections
Irritation from wind or smoke
Tired eyes
Excessive tearing
Eyelids stuck in the a.m.
Burning
Soreness
Itching
Submit
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