LASIK Screening Questionnaire

This LASIK/PRK Questionnaire is the beginning step to determining if you may be a good candidate. Please read and answer every question. The questionnaire allows us to learn necessary information about YOUR eye health history and medical history. Patients who are set up for a LASIK/PRK Screening and/or a LASIK/PRK Evaluation are NOT guaranteed to receive surgical treatment at Griffin Eye Center. The surgeon reserves the right to not go forward with any procedure.

If you prefer to fill out a paper form, please download the questionnaire here.

Name(Required)
Phone
Email(Required)
Are you age 21 or older?(Required)
Have you had a complete eye exam within the last 1.5 years?(Required)
Do you currently wear glasses or contact lenses regularly?(Required)
Are you pregnant or nursing or considering pregnancy at this time?(Required)
Does your glasses / contact lens prescription change often?(Required)
Do you wear Bifocals or Reading glasses?(Required)
Have you ever had any type of eye surgery?(Required)
Do you have double vision or wear prism in your glasses?(Required)
Do you have dry eyes?(Required)
Have you ever been told that you have lazy eye?(Required)
Have you ever been told you have Keratoconus?(Required)
Do you rub your eyes?(Required)
Have you ever been told that you have glaucoma?(Required)
Do you have chronic migraines?(Required)
Do you have auto-immune disorders?(Required)
Do you have thyroid issues?(Required)
Have you ever had a herpetic infection in your eyes?(Required)
Do you have any other major medical issues/concerns?(Required)
Do you have any other conditions that would impact your surgical experience, such as, anxiety, depression, PTSD, white coat syndrome?(Required)