Black Hills Regional Eye Institute Laser Vision Center

LASIK Screening Questionnaire

  1. Do you have trouble seeing far away or up close?


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

  3. What is your age?


  4. Are you interested in seeing well up close (reading) without glasses?

  5. Do you wear contact lenses, glasses, or reading glasses? Check all that apply:


  6. Would your daily activities improve if you were to become less dependent on glasses and contacts?


  7. 7. Over 98% of LASIK patients see 20/40 or better after surgery. The results of 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?

  8. Client privacy is important to us. If you have any questions please see our privacy policy here.