Self Evaluation

For Total Precision call: 303.499.2020 | 1810 30th St. Suite B, Boulder CO. 80301
For questions after hours, Text: 720 583 EYES (3937)

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1. Without glasses or contacts, do you have trouble seeing far away or up close?

Up Close
Far Away
Both

2. How interested are you in being able to play sports without glasses and contacts?

It's very important to me NOT to wear glasses for activities such as sports.
It's not important to me. I do not mind wearing glasses.

3. How old are you?

18 - 21
22 - 44
45 - 65
66+

4. If you are over 44 years old and you don’t wear glasses or contacts while driving, can you read the paper without reading glasses?

Not Applicable
Yes
No

5. If you are over 44 years and you wear glasses or contacts while driving, can you read the paper while wearing these without using a bifocal or reading glasses?

Not Applicable
Yes
No

6. If you are over 45 years old, do you want to see well enough up close to read without reading 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.

7. Do you wear contact lenses or glasses most of the time?

Glasses
Contacts

8. If you wear contacts have you experienced any of these complications?(Select more than one if necessary.)

Chronic Dryness
Giant Papillary Conjunctivitis (GPC)
Corneal Abrasion
Corneal edema (swelling)
Corneal Neovascularization
Corneal Warpage
Corneal Ulcer

9. Would the quality of your life improve if you were less dependent on glasses and contacts?

Yes
No
Maybe

110. Over 98% of LASIK patients see 20/40 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 that are comparable to those risks associated with contact lens wear. Are you willing to discuss these risks with our LASIK coordinator?

Yes
No

11. After careful examination and consultation with our previous patients, many have been told by others that they are not a candidate when in fact they are. Have you ever been told you are not a candidate?

Yes
No

12. Most likely you are a candidate for Laser Vision Correction, LASIK, or PRK; would you like to schedule a free consult so that we can perform specific diagnostic tests to be absolutely certain?

Yes
No

It appears that a Free LASIK consultation would benefit you. According to your test answers you may suffer from nearsightedness, farsightedness or astigmatism. You may also suffer from presbyopia.cataracts. In order for us to contact you regarding this test please fill out the form on the following page. By placing your initials in the box below, you agree to allow us to contact you regarding the results of this test.

Initials

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Based in Boulder, CO, Beyer Laser Center is a premium provider of laser vision correction and eye care services. If you are interested in improving your sight, choose Dr. Beyer for your LASIK in Colorado.

Our Surgeons-
Craig F. Beyer, D.O.-
Richard M. Stewart, M.D.-
Chet E. Reistad, M.D.-
Peter H. Lehmann, O.D.-
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