Suitability Quiz

What is your age? *

Under 20
20 - 47
48 - 64
65+

Age Unsuitable

Generally we do not perform a corrective laser eye surgery procedure on anyone under the age of 20 unless there is a compelling reason, ie career path. We are happy to discuss specific cases question@lasik.co.nz It is preferable to wait until you are at least 20 years of age and have had no change in your spectacle lens strength for at least twelve months, we would be happy to record baseline measurements if you are close to 20years old and compare to check future stability of your spectacle prescription.

What do you mainly use to correct your vision? *

Glasses
Contact Lenses
Neither

How often do you wear your glasses? *

All of the time
Some of the time

Do glasses get in the way of your everyday activities, like sport, reading, work?

YesNo

Do you ever get dry eyes from your contact lenses?

YesNo

During waking hours, how many hours per day do you leave your contact lenses out? *

0 - 1
1 - 2
2+

Without glasses or contact lenses, do you have trouble seeing far away or up close? *

Far away
Up close
Both
None

How interested are you in seeing at a distance, driving or playing golf without glasses after your surgery? *

It's very important to me NOT to wear glasses for distance vision.
It's not important to me.

Are you interested in seeing well up close (reading) without glasses after your surgery? *

It's very important to me NOT to wear reading glasses.
It's not important to me.

If you had to wear glasses for one of the following activities, which one would you to most be willing to wear glasses for? *

Reading fine print
Using a computer or cooking
Driving a car

If you could have good vision for driving during the day without glasses, and good near vision without glasses in most situations, would you be able to tolerate some halos and glare around lights at night? *

If you could have good distance vision day and night, and good vision for computer work, without glasses, would you be willing to wear glasses for reading fine print and small type? *

Based on the options scale below how would you rank your personality? *

Easy Going
In the middle
Perfectionist

Do you have cloudy, blurred, foggy, filmy or dim vision? *

Do you have problems with night vision such as glare from oncoming headlights? *

Full Name *

Email address *

Telephone Number *

Date of Birth

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