West Georgia Eye Care LASIK Self Evaluation
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First Name
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Last Name
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Contact Number
Email address
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Please select today's date
Do you have any of the following?
Myopia (Near Vision)
Hyperopia (Far Vision)
Astigmatism
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Do you currently wear reading glasses?
Yes
No
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Have you ever had eye surgery or an eye injury?
Yes
No
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How would you evaluate your night vision?
Good
Fair
Poor
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At this time, what is the most important issue to you regarding LASIK?
Improving my lifestyle being free from contacts and/or glasses
Affordability
Questions about the procedure itself
Other
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Have you ever been diagnosed with any of the following: Keratoconus, Diabetic Retinopathy, Lupus or Rheumatoid Arthritis?
Yes
No
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Are you in general good health?
Yes
No
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What is your age group?
Under 20
21-40
41-64
65+
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Indicates Response Required