Lasik Questionaire for Eye Specialists of Ohio

Lasik Questionaire

Thank you for taking the first step towards a life after dependency on glasses and contacts. To better assist us with your personal eye care, please take a few moments and complete the following LASIK questionnaire.

I would like to request an appoint with the following Doctor:

Harmeet Chawla, MD - Medical Director
Terry Schultz, OD - Center Director
Himanshu Joshi, DO - Clinical Ophthalmologist
Patrick D. Schumacher - Clinical Ophthalmologist
Jay S. Egolf, MD - Clinical Ophthalmologist
Stacia Waddle, OD - Clinical Optometrist

Enter Patient's information below:

	First Name:
	Last Name:
	Address:
	Address 2:
	City:
	State/Province:
	Zip/Postal Code:
	Country :
	Day Phone Number:
	Evening Phone Number:
	Email Address:
	New Patient ?	Yes No

Existing Conditions

	Do you wear glasses?	Never Sometimes Frequently Always
	Do you wear contact lenses?	Never Sometimes Frequently Always

Do you need assistance with your current vision

	Close up	Never Sometimes Frequently Always
	Far away	Never Sometimes Frequently Always

While active in Sports

	Do you wear glassses?	Never Sometimes Frequently Always
	Do you wear contact lenses?	Never Sometimes Frequently Always

Personal Appearance

	People say you look better without glasss?	Never Sometimes Frequently Always

Would career/business activities improve with

	Glasses?	Never Sometimes Frequently Always
	Contact Lenses?	Never Sometimes Frequently Always
	Lasik or other Solutions	Never Sometimes Frequently Always

Personal Objectives

	Be able to read without glasses?	Yes Maybe No
	Be able to read without contact lenses?	Yes Maybe No

Age

	My age is

Lasik Candidate

	How soon would you be interested in improving your vision?	ASAP 3-6 mo. 6mo-1yr Not Certain

	Comments:	Confirm My Appointment By: Email Phone

		HOME \| DOCTORS \| AFFILIATE DOCTORS \|STAFF \| MEDICAL INFORMATION \| LOCATIONS Copyright© 2010 Eye specialists of Ohio All rights reserved