Vision Correction Lifestyle Questionnaire

Your eyes are very important and we would like to know how you use your eyes on a daily basis. Along with your eye exam, this information will assist us to recommend the best options for your personal visual goals.

• Do you wear glasses now?*
  • No.
  • If Yes All the time
  • Sometimes
  • Only for Far Distance
  • Only for Reading
  • Only for the Computer
• Do you have a particular motivation for wanting laser vision correction?*
• Do you drive at night?*
  Often Occasionally

Any other regular activities not listed?*

What has prevented you from proceeding with laser vision correction before now?*

How soon do you want to have your surgery done?*

Please select an option to describe your personality as best you can:*

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