This form is designed to obtain similar information from you that we would obtain during your office visit. This form will also help determine if you are a good candidate for LASIK.

Please note that all fields with a red * next to them are required in order to submit the form properly. Thank you.

Personal Information:

Prefix:
*First Name / MI:  
*Last Name:
*Email Address:
Date of Birth:
Address:
City:
State / Zip:
*Day Phone#:
Evening Phone#:
Facsimile#:
Employer:
Occupation:
Eye Care Provider:
If other, please supply:  

Ocular History :

1. I primarily wear:
     Glasses    Contact Lenses
     Glasses and Contact Lenses
     If Contact Lenses:
     Soft Daily   Soft Extended    Toric
     Gas Permeable Lenses Hard Contact Lenses

 

2. Do you wear reading glasses over your contact lenses, or take your glasses off to read?
     Glasses over contact lenses
     Take glasses off to read

 

3. If you are a contact lens wearer and you are over the age of 40, has your eye care provider ever discussed monovision with you?
     Yes     No

 

4. Has your prescription been changing significantly every year, and enough that you can't wait to get to the eye doctor because you can't see well enough?
(> -0.50/yr)
     Yes     No

 

5. Are you dependent upon (hard) contact lenses for good vision / unable to see as well with glasses or soft contacts?
     Yes     No

 

6. Have you ever suffered from an eye injury?
     Yes     No

If "yes", did it result in significant vision loss?
     Yes     No

 
7. Have you had previous vision correction surgery?
     Yes     No

Expectation Profile

Please check the comment that best describes you for each of the following:

1.





I dislike being dependent on glasses for clear vision. I have often wished I did not have to wear corrective lenses.

I don't mind wearing glasses or contacts for most activities.

I like wearing glasses and would feel uncomfortable without them.



2.




I was never a good contact lens candidate/wearer.


I don't mind wearing contact lenses.


3.






Wearing corrective lenses restricts my participation in sports and other activities.

Wearing corrective lenses rarely interferes with my extracurricular activities.

Corrective Lenses give me excellent vision for all activities.


4.





My overall appearance is improved without glasses.

I don't mind the way I look in glasses.

I like the way I look in glasses.


5.






I worry about losing my corrective lenses. Without them I fear that I would be totally disabled.

There are times that I have wondered what I would do if I lost a contact or broke my glasses.

I rarely think about how dependent I am upon glasses or contacts.


6.





Having good vision without corrective lenses is more important than having great vision with corrective lenses.

I am a perfectionist and little irregularities bother me.

7.






I would be happy if my vision was greatly improved, even if I still had to wear corrective lenses some of the time.

I expect to end up with vision that is as good as my contacts or glasses after my procedure, but would feel that vision almost as good would still be a success.

I would be very upset if I did not end up with perfect vision after my procedure and would probably consider the entire experience a failure.


8.





I usually adjust well to change.

I am somewhat accepting of change.

I don't accept changes easily.


9.





I am a fairly easy-going person.

I try not to let things bother me.

I get upset or stressed out easily when things don't seem to happen in just the way I had planned or expected.


10.





Not wearing corrective lenses would open new career opportunities for me.

My occupation is not significantly impacted by any visual limitations.

11.





I understand that 5% to 10% of patients will require fine-tuning of their procedure.

If I needed more correction after my procedure, I would be devastated.


Profile Information:

1. Activities I enjoy:

Jog or Run
Biking
Hiking
Going to Gym
Traveling

 Tennis
Golfing
Skiing
Working Out
Scuba Diving 		Basketball
Swimming
Surfing
Boating


2. Please indicate your level of interest in laser vision correction:






I definitely want to have the LASIK procedure done as soon as possible, as I know I am a candidate.

I am very interested in having the LASIK procedure performed, and will probably proceed within the next year.

I am somewhat interested in having the procedure performed, but want to get more information. I probably will not have the procedure performed in the next 12 months.

I am interested in the LASIK procedure but would prefer to be contacted by mail (and e-mail) only. (Address and e-mail required). I will contact the center when I am ready.

3. Why are you interested in laser vision correction:



My vision is so poor that I worry about my safety when I'm not wearing lenses or glasses.



By the end of the day, my lenses are dry and irritate my eyes.



I don't like putting something into my eyes.



Cleaning and caring for my lenses is time consuming.



Glasses and/or contacts interfere with my daily activities and hobbies.



I don't feel like I look good when wearing glasses.


4. How did you hear about McGlothan Eye Institute?
(Please check all that apply)


Eye care provider

Print (newspaper, magazine, other)
If print, specify the publication:

Sports Promotional:
Type the name of promotion:   

2nd Generation
Type the family name:            

Internet
List what Search Engine used:  
List keywords/phrases used:    

Radio Station
Please type the station ID:       

Direct Mail

Outdoor
Please specify outdoor:           

Employer/Corporate Program
Company Name:                    

Insurance
Please type Insurance Name:  

Event

MEI Staff
Staff Member Name:              


Other                                   


5. How did you find our On-line Consultation?

Found while on site
Eye Care Provider
Former Patient
McGlothan Staff Member
Radio
Print
CD-Rom Business Card

6. What type of vision insurance do you have?

Aetna
BCBS
CCN
Cigna
Davis
ECPA
HIP
Humana
United - Vision Select
VSP
None
Other:

 
 

McGlothan Eye Institute
3498 S. 4th Street
Terre Haute, IN 47802
812.478.5550


Evansville Office
6540 Logan Dr.
Evansville, IN 47715
812.402.3937