Form Test Refractive Surgery Candidate Quiz Introduction for Patients: Curious if you might be a candidate for refractive surgery? Take this quick quiz to find out if LASIK, PRK, or another vision correction option might be right for you. It only takes a minute! How old are you?(Required) Under 18 years old 18-40 years old 41-55 years old Over 55 years old Is your prescription stable (meaning no major changes in your vision) over the last year?(Required) Yes No Do you have any of the following health conditions? (Check all that apply)(Required) Autoimmune disorders (e.g., rheumatoid arthritis, lupus) Unstable Diabetes Eye diseases (e.g., keratoconus, glaucoma) None of the above Do you have dry eyes or experience discomfort due to dryness?(Required) Yes, frequently Sometimes No, rarely Are you pregnant or nursing?(Required) Yes No What is your main goal with refractive surgery?(Required) To reduce dependency on glasses or contacts To achieve perfect 20/20 vision I have a specific vision problem (like astigmatism) I’d like corrected Please provide us with your contact details to be sent a copy of your quiz resultsFull Name(Required) First Last Email(Required) CommentsThis field is for validation purposes and should be left unchanged. Dry Eye Disease Quiz Introduction for Patients Dry, irritated, or uncomfortable eyes? You might have dry eye disease. Take this quick quiz to learn more about your symptoms and whether you should see a specialist. How often do you experience dryness in your eyes?(Required) Never Rarely Occasionally Frequently Always Do you often feel a gritty or sandy sensation in your eyes?(Required) Yes Sometimes No How often do your eyes feel tired, especially after prolonged screen time or reading?(Required) Never Rarely Sometimes Often Always Do you notice excessive tearing or watery eyes, especially when outside in windy or dry conditions?(Required) Yes, frequently Sometimes No Do you wear contact lenses?(Required) Yes No Do you often use over-the-counter artificial tears or eye drops for relief?(Required) Yes, every day Yes, occasionally No Do your eyes often feel sensitive to light or become easily irritated?(Required) Yes No Please provide us with your contact details to be sent a copy of your quiz results" and add the fieldsName(Required) First Last Email(Required) PhoneThis field is for validation purposes and should be left unchanged. Cataract Surgery Candidate Quiz Introduction for Patients: Are cataracts affecting your vision? Find out if you might benefit from cataract surgery by taking this short quiz. It only takes a minute to complete! How would you describe your vision quality recently?(Required) Clear, no issues Slightly blurry sometimes Frequently blurry, even with glasses/contacts Constantly blurry or foggy Do you have trouble seeing at night, especially while driving?(Required) No difficulty Rarely Often Always Do you find that bright lights or headlights cause glare or halos in your vision?(Required) No Occasionally Often Almost always Have you noticed that colors seem faded or less vibrant than before?(Required) Yes, significantly Yes, a little No change Have your glasses or contact lens prescription changed frequently in the past year?(Required) Yes, multiple times Yes, once No How do your daily activities feel with your current vision?(Required) No impact on daily activities Minor difficulty with some tasks (e.g., reading small print) Significant difficulty with some tasks Unable to perform certain activities due to vision issues Have you been diagnosed with cataracts by an eye doctor?(Required) Yes No I’m not sure Please provide us with your contact details to be sent a copy of your quiz results" and add the fieldsName(Required) First Last Email(Required) CommentsThis field is for validation purposes and should be left unchanged.
