Eye Surgery Request

Name:

Surname:

Age:

Sex:

Male Female

Address

Phone

Mobile

e-Mail

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Diabetes

Autoimmune disease (for example, AIDS, lupus, rheumatoid arthritis, multiple sclerosis, or myasthenia gravis)

Immunocompromised for any reason

Collagen vascular disease

To the best of my knowledge, I have none of these conditions

Are you currently taking medications, such as steroids or immunosuppressants, which can slow or prevent healing?

Yes No

Do you have any of the following conditions? (Please select all that apply.)

	Keratoconus or other corneal thinning disorder
	Corneal scarring
	Glaucoma
	Cataracts
	Ocular herpes diagnosed in past year
	Retinal disease
	Dry eye
	To the best of my knowledge, I have none of these conditions

What type of refractive error do you have?

Nearsightedness (myopia) -- you have trouble seeing distance

Farsightedness (hyperopia) -- you have trouble seeing up close

Don't know

Do you have astigmatism?

Yes No

What level of hyperopia / myopia do you have?

Low to high (+5 /-5 or less)

Very high (greater than +5/-5)

None

What degree of astigmatism do you have?

Has your vision correction -- that is, your glasses or contact lens prescription -- changed over the past year or two?

Yes No