In order to be suitable for refractive surgery there are certain requirements:
You must be at least 18 years old and the degree of your refractive error must be steady for at least a year.
There should be no chronic disorders of the retina or cornea or other ophthalmological illnesses or inflammation.
If you are a woman, refractive surgery is to be avoided during pregnancy or nursing.
The pre-operative check will determine whether you can be subjected to laser treatment in the event that you fulfill all anatomical and optical conditions.

Personal data >

What frustrations do you currently have that relate to not being able to see as well as you like ?

List three or four of the reasons why you are now considering a vision correction procedure?

Please share with us some of the physical activities that you hope to further participate in after your procedure?

What restrictions do you have now because of your use of contacts or glasses?

What activities will you be able to more fully participate in after your vision is corrected?

Have you visited our website?    Yes    No
What led you to make an appointment with us?

If you were referred to us, who referred you?

Doctor (name)    Friend/Family (name)

Glasses >

1. What are your prescription details:
SPH   CYL   AXIS
OD (RIGHT EYE) D D
OS (LEFT EYE) D D
2. How often do you wear eyeglasses or contact lenses for distance vision?

Not All    Part-time    Full-time  

3. Do you need eyeglasses for reading?    Yes    No
4. Do you currently wear contact lenses? (if no, skip to 6)    Yes    No
5. What kind of contact lenses do you wear now?

Soft    Hard    Rigid Gas permeable  

6. How long have your contacts been out?

Ocular history >

7. List all eye surgeries you have had. Indicate which eye and the date of surgery

8. List all other surgeries you have had, with dates:

9. List eye injuries with dates:

10. List any eye diseases you have:

General Medical History >

Do you now or did you in the past have any of the following conditions
Atopic disease Yes No
Rheumatoid Arthritis Yes No
Autoimmune disease Yes No
Diabetes Yes No
Hepatitis Yes No
HIV infection Yes No
Keloid formation Yes No
Other medical problems Yes* No
*If yes, please specify

List all eye drops you use, which eye, and how often you use them:

List all other medications you take with dosage and frequency:

List any medications you are allergic to:

If female, are you or might you be pregnant?    Yes    No
If female, are you trying to become pregnant?    Yes    No

Family medical history >

List any diseases that run in your family:

(*) Mandatory field