Am I a Good CK Candidate?

Please fill out then print this checklist, and bring it with you for your Consultation.

Yes

1. Do you have trouble with distance vision?

2. Do you have trouble seeing up close?

3. Do you wear reading glasses for close work?

If yes, how many years have you been wearing them?

4. Do you have night vision problems?

If yes, please describe:

5. Do you have dry eyes?

If yes, please describe:

6. Are certain sports or hobbies you’re interested in compromised by your near vision?

If yes, please describe:

7. Do you have severe diabetes or severe allergies?

8. Do you have any active eye diseases, for example glaucoma or cataracts, or other health problems such as collagen, vascular, autoimmune or immunodeficiency diseases (for example: Rheumatoid Arthritis, Lupus, AIDS)?

9. Would you be satisfied with a procedure that allows you to function in daily life without reading glasses, but still requires you to use them for prolonged close work?

10. What type of work do you do?

11. How many hours per day do you spend
on the computer?

12. How many hours per day do you spend reading, either for business or for pleasure?

13. Describe any vision issues that occur when driving.