You can always press Enter⏎ to continue
Lasik Self-Test
Hi there, please fill out and submit this form.
7
Questions
START
1
What is your age?
*
This field is required.
Under 18
19-35
36-55
55+
Previous
Next
Submit
Press
Enter
2
I usually wear ...
*
This field is required.
Glasses
Contacts
Both
None of the above
Previous
Next
Submit
Press
Enter
3
Without corrective lenses you have ...
*
This field is required.
Trouble seeing far away
Trouble seeing up close
Overall blurry vision
Trouble with reading
Previous
Next
Submit
Press
Enter
4
Have you ever been told that you have astigmatism?
*
This field is required.
YES
NO
Previous
Next
Submit
Press
Enter
5
Have you ever been told that you have dry eyes?
*
This field is required.
Yes
Not sure
No
Previous
Next
Submit
Press
Enter
6
How interested are you in being able to play sports without glasses and contacts?
*
This field is required.
It’s important for me now to wear glasses for sports activities
I don’t mind wearing glasses
Previous
Next
Submit
Press
Enter
7
Would your career or business activities improve if you were to become less dependent on glasses and contacts?
*
This field is required.
Yes
No
Maybe
Previous
Next
Submit
Press
Enter
Should be Empty:
Question Label
1
of
7
See All
Go Back
Submit