LASIK Self-Evaluation TestBerks Eye Physicians & Surgeons, Ltd. First Name: * Last Name: * Email: * Phone: * What is your age? Under 18 18 - 40 40 - 50 50+ Do you have dry eye problems? None Mild Moderate Severe Has your glasses or contact prescription been stable for at least 12 months? Yes No Not sure Do you know your prescription? +5 to 0 0 to -5 5 to -10 0 or None Not Sure Do you wear reading glasses or bifocals? Yes, Reading Glasses Yes, Bifocals (or Trifocals) No Have you ever had an eye injury or eye surgery? Yes No Over 98% of LASIK patients see 20/20 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. Are you willing to discuss these risks with our LASIK coordinator? Yes No Questions/Comments? Email me about news & special offers