Refractive Surgery Questionnaire

Print, fill out, and bring to your appointment if you wish to speed things up.

Name:__________________________________________ Date:___/___/_____

Please read and evaluate the following 10 statements. Choose YOUR top 5 only, according to importance to YOU. Rate them 1-5, with 1 being most important and 5 least important, leave the remainder blank.

The most important aspects as it pertains to my vision are:

Great distance vision._____

Great near vision._____

Great distance AND near vision._____

Independence from contact lenses or glasses (short term). _____

Never needing contact lenses or glasses again._____

I do not like the way glasses make me look._____

My hobbies or occupation requires “perfect vision”. _____

I can not tolerate contact lens wear._____

My glasses or contact lenses interfere with my recreation._____

I just want to be able to wake up and see clearly.