CS LASIK Institute
(719) 258-1260
9320 Grand Cordera Parkway, Suite 255 Colorado Springs, CO 80924
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(719) 258-1260
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First Name
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Last Name
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Height
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Weight
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Where did you first hear about CS LASIK Institute?
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Have you ever seen CS LASIK Institute on Facebook or Instagram?
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Yes
No
Based on WHERE you first heard about us, please rate your first impression of CS LASIK Institute. 5=best 1=worst
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5
4
3
2
1
Was scheduling your consultation easy and convenient?
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Yes
No
Have you been screened for vision correction before?
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Yes
No
When did you start your laser vision correction research?
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5-10 years ago
1-5 years ago
less than 1 year ago
What has held you back from laser vision correction?
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Medical issues
Affordability
Fear
Life Events
Career
Unstable vision
How are you feeling about your consultation?
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Fearless & Pumped "Let's do this!"
Hopeful but Nervous "I hope this goes well."
Stressed "Am I candidate?"
Excited "Oh happy day, finally!"
Anxious "Is it over yet?"
What favorite activity are you most excited about doing lens-free?
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Lifestyle Vision Questionnaire
Employer
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Occupation
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Please select the occupational category that is most applicable
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Military or DOD
Allied Healthcare Professional
None of the above
Do you have an FSA or HSA with your employer?
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Yes
No
How would you best describe your personality?
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Type A - perfectionist, competitive, likes quick results
Type B - relaxed, laid-back, patient, and adaptable
Type C - highly conscientious, passive, perfectionist
Type D - tends to worry, cautious, shy
Do you feel that your vision has been stable for the past 12 months?
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Yes
No
How do you feel about wearing glasses?
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How old are the lenses in your glasses?
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Less than 1 year old (previous eye exam records will be required)
1-2 years old
2-3 years old
3-4 years old
5+ years old
Do you wear reading glasses, take off your glasses, or wear bifocals to read?
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Reading glasses
Bifocals
Progressives
Take glasses off to read
Not Applicable
How important is it for you to read or use the computer without glasses?
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Very important
Important
Not important
How many hours per day do you read?
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How many hours per day do you use a computer?
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What is your most common near vision activity?
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Precision work/Fine print
Phone/Tablet
Newspaper/Books
Recipes/Labels
Draw/Paint/Art
Do you drive at night?
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Yes
No
If yes to driving at night:
Occasionally
Nightly
Professionally
Please choose all that you may notice while day or night time driving.
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Starburst
Glare
Halos
None of the above
If you chose any of the above: starburst, glare or halos, please rate the severity.
Mild
Moderate
Severe
Please choose all that apply to you on a daily basis.
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Fluctuation in vision throughout the day
Eye redness
Eye burning
Eye itching
Eye dryness
None of the above
Have you ever suffered from an eye injury?
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Yes
No
Have you had any previous eye surgeries?
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Yes
No
Have you ever been diagnosed with cataracts?
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Yes
No
Do you have a history of lazy eye?
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Yes
No
Do you have any history of dry eye treatment?
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Yes
No
Have you ever been diagnosed with a corneal eye disease?
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Yes
No
Have you ever been diagnosed with an Autoimmune disease?
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Yes
No
(Female patients only) Are you currently pregnant?
Yes
No
(Female patients only) Are you currently nursing?
Yes
No
I stopped nursing less than 3 months ago.
(Female patients only) Do you have an infant less than 3 months old?
Yes
No
HIPPA Acknowledgement and Consent Form
HIPAA Acknowledgement and Consent Form I understand that, under the Health Insur-ance Portability & Accountability Act of 1996 (HIPAA), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to: *Conduct, plan and direct my treatment and follow-up care among the multiple healthcare providers who may be involved in that treatment directly or indirectly. *Obtain payment from designated third-party payers. *Conduct normal health care operations such as quality assessments or evaluations, and physician certifications. I have been informed by you of your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information (copy availa-ble in office). I have been given the right to review such Notice of Privacy Practices prior to signing this consent. I understand that CS LASIK Institute has the right to change its Notice of Privacy Practices from time to time and that I may contact CS LASIK Institute at any time at the address below to obtain a current copy of the Notices of Privacy Practices. I understand that I may request in writing that CS LASIK Institute restrict how my pri-vate information is used or disclosed to carry out treatment, payment or health care operations. I also understand CS LASIK Institute is not required to agree to my request-ed restrictions, but if CS LASIK Institute does agree, then it is bound to abide by such restrictions. I understand that I may revoke this consent in writing at any time, except to the extent that the organization has taken action relying on this consent. You may refuse to sign this consent. Please type your name below to sign consent.
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