Self Test - Shady Grove Ophthalmology

WELCOME TO OUR LASIK SELF TEST

TO START

PLEASE TELL US HOW OLD YOU ARE

Under 18

19-39

40-59

60+

QUESTION 2:

DO YOU WEAR...

Glasses

Contacts

Glasses & Contacts

Neither

QUESTION 3:

WITHOUT YOUR CORRECTIVE LENSES, DO YOU HAVE...

Trouble seeing far away

Trouble seeing up close

Overall blurry vision

Trouble with reading only

QUESTION 4:

HAVE YOU EVER BEEN TOLD YOU HAVE ASTIGMATISM?

Yes

No

QUESTION 5:

WHAT EMAIL SHOULD WE SEND THE RESULTS TO?

QUESTION 6:

WHAT IS YOUR FIRST NAME?

QUESTION 7:

WHAT IS YOUR LAST NAME?

Last Name

QUESTION 8 (THE FINAL ONE!):

WHAT PHONE NUMBER CAN WE CALL/TEXT YOU AT?

Phone

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