• A A A

    • LASIK Self Evaluation Test

    The doctors and staff at Boling Vision Center want to help you determine whether or not you are a candidate for LASIK eye surgery. In order to better understand if you would be a good candidate for LASIK laser vision correction, please take a moment to complete the form below. Once your visual needs and lifestyle requirements have been determined, it will be easier for our LASIK coordinator to answer any of your questions relating to LASIK in Michiana or any other vision correction procedure that might be applicable.

    Your Name (required)

    Primary Phone

    2nd Phone

    Your Email (required)

    1. Do you have trouble seeing far away or up close?

     Up close Far away Both

    2. What is your current method of vision correction?

     Glasses  Soft contact lenses  Toric soft contact lenses  Gas permeable lenses  Combination of the above.

    3. What is your age?

     Under 18  18 - 40  40 - 69  69+

    4. Are you interested in seeing well up close (reading) without glasses?

     It's very important to me NOT to wear reading glasses.  It's not important to me.I do not mind wearing reading glasses to see things up close.

    5. Would your career or business activities improve if you were to become less dependent on glasses and contacts?

     Yes No Maybe

    6. Do you know your visual prescription?

     Yes No

    7. Do your eyes hurt after prolonged eyewear use?

     Yes No

    8. Do you have astigmatism?

     Yes No

    9. Has your prescription been stable over the last two years?

     Yes No

    10. Over 94% of LASIK patients see 20/20 or better after surgery. The results of LASIK laser vision correction have been tremendous for literally millions of people. Despite the amazing safety and results of this procedure there are associated risks. Are you willing to discuss these risks with our LASIK coordinator?

     Yes No

    11. If you have been told that you are not a candidate for LASIK, would you like to hear about other possible options?

     Yes No