September 2022 | Northeastern Eye Institute

September 2022
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LASIK SELF-TEST

This test is not a replacement for a comprehensive eye examination. In the event of any eye-related concerns or issues, it is crucial to promptly contact your healthcare provider or eye care professional. The purpose of this self-test is to provide educational insights into your eye health and serve as a guiding resource.

Are you 18 years of age or older?

Yes

Do you have a stable eyeglass or contact lens prescription for at least the past year?

Yes

Have you experienced any significant changes in your vision prescription within the last 12 months?

Yes

Have you been diagnosed with any eye conditions such as keratoconus or corneal dystrophy?

Yes

Are you in good overall health without uncontrolled diabetes, autoimmune disorders, or other systemic diseases that may affect healing?

Yes

Are you aware that LASIK surgery has its limitations and that it may not completely eliminate your need for glasses or contacts?

Yes

Have you been free from any eye infections or injuries in the past six months?

Yes

Do you have stable eye health without significant conditions such as glaucoma or cataracts?

Yes

Are you willing to adhere to the pre and post-operative care instructions provided by your LASIK surgeon?

Yes

Have you had a comprehensive eye examination within the last year to assess your eligibility for LASIK surgery?

Yes

Do you have a corneal thickness within the acceptable range for LASIK surgery?

Yes

Do you have a stable eye prescription that falls within the treatable range for LASIK surgery?

Yes

Do you have realistic expectations about the outcomes of LASIK surgery?

Yes

Have you been wearing contact lenses regularly, if applicable, and are willing to discontinue them before the LASIK evaluation?

Yes

Have you had stable vision without any significant fluctuations in the past year?

Yes

Have you had any eye surgeries or procedures in the past?

Yes

Do you have any corneal scarring or irregularities that may affect the outcome of LASIK surgery?

Yes

Do you understand and accept the potential risks and complications associated with LASIK surgery?

Yes

Are you committed to attending follow-up visits after the surgery as recommended by your LASIK surgeon?

Yes

Have you discussed the possibility of LASIK surgery with an eye care professional or LASIK surgeon?

Yes

Do you grant us permission to contact you in the event that your assessment reveals you may be a candidate for LASIK eye surgery.

Yes

Please fill out the information below to get your results emailed to you.

Name

Phone

Time is Up!

Time's up

Gluacoma SELF-TEST

Are you 40 years of age or older?

Yes

Do you have a family history of glaucoma?

Yes

Have you noticed any changes in your vision recently?

Yes

Do you experience frequent headaches or eye discomfort?

Yes

Have you ever been told that you have high eye pressure?

Yes

Have you had any previous eye injuries or surgeries?

Yes

Do you have any existing medical conditions, such as diabetes or hypertension?

Yes

Are you of African, Asian, or Hispanic descent?

Yes

Have you noticed a gradual loss of peripheral (side) vision?

Yes

Do you experience blurred or hazy vision?

Yes

Do you have difficulty adjusting to dark or dimly lit environments?

Yes

Have you noticed halos or glare around lights?

Yes

Do you experience eye fatigue or strain after prolonged activities like reading or computer use?

Yes

Have you ever been diagnosed with narrow-angle or closed-angle glaucoma?

Yes

Do you use medications that may increase your risk of developing glaucoma (e.g., corticosteroids)?

Yes

Have you had any episodes of sudden vision loss or eye pain?

Yes

Have you noticed any changes in the color or appearance of your iris?

Yes

Do you have corneal thickness measurements within the normal range?

Yes

Do you have thinning or cupping of the optic nerve as observed in eye examinations?

Yes

Have you had a comprehensive eye examination within the last year to evaluate your risk for glaucoma?

Yes

Do you grant us permission to contact you in the event that your assessment reveals you may have Glaucoma?

Yes

Please fill out the information below to get your results emailed to you.

Name

Phone

Time is Up!

Time's up

Cataract SELF-TEST

Are you 60 years of age or older?

Yes

Do you have a family history of cataracts?

Yes

Have you noticed a gradual decline in your vision clarity?

Yes

Do you experience difficulty reading or performing close-up tasks?

Yes

Have you noticed increased sensitivity to glare, especially in bright sunlight or while driving at night?

Yes

Do colors appear dull or faded to you?

Yes

Have you experienced frequent changes in your eyeglass prescription?

Yes

Have you noticed a halo effect around lights?

Yes

Do you have diabetes or a history of other medical conditions, such as long-term steroid use?

Yes

Have you undergone eye surgery or sustained eye injuries in the past?

Yes

Do you have a history of excessive UV exposure (e.g., long hours outdoors without proper eye protection)?

Yes

Do you have a history of smoking?

Yes

Have you noticed double vision in one eye?

Yes

Do you have difficulty seeing in low-light environments?

Yes

Have you noticed a cloudiness or milky appearance in your eye(s)?

Yes

Have you experienced a decrease in contrast sensitivity (ability to distinguish between shades)?

Yes

Do you frequently need to adjust the brightness on your electronic devices?

Yes

Do you have trouble identifying faces or reading signs from a distance?

Yes

Have you had a comprehensive eye examination within the last year to evaluate your risk for cataracts?

Yes

Have you experienced a significant change in your overall visual quality?

Yes

Do you grant us permission to contact you in the event that your assessment reveals you may have Cataracts?

Yes

Please fill out the information below to get your results emailed to you.

Name

Phone

Time is Up!

Time's up

Dry eye SELF-TEST

Do you frequently experience dryness or discomfort in your eyes?

Yes

Do your eyes feel gritty or like there's something in them?

Yes

Do your eyes feel irritated or red?

Yes

Do you often use artificial tears or eye drops to relieve dryness?

Yes

Do you experience blurred vision, especially towards the end of the day?

Yes

Do your eyes feel worse in dry or windy environments?

Yes

Do you spend extended periods of time looking at screens (e.g., computer, smartphone)?

Yes

Do you wear contact lenses regularly?

Yes

Do your eyes water excessively as a response to dryness?

Yes

Have you noticed a decrease in your overall tear production?

Yes

Do you have a history of autoimmune disorders, such as Sjögren's syndrome or rheumatoid arthritis?

Yes

Do you take medications that are known to cause dryness as a side effect (e.g., antihistamines, certain blood pressure medications)?

Yes

Do you have a history of eye allergies?

Yes

Do you have a history of eye surgeries, such as LASIK or cataract surgery?

Yes

Do you experience discomfort or dryness in other parts of your body, such as the mouth or nose?

Yes

Do you frequently wake up with dry or sticky eyelids?

Yes

Do you notice a decrease in your ability to wear contact lenses comfortably throughout the day?

Yes

Do you experience a burning sensation in your eyes?

Yes

Have you had a comprehensive eye examination within the last year to evaluate your risk for dry eyes?

Yes

Have you tried over-the-counter remedies for dry eyes with limited relief?

Yes

Do you grant us permission to contact you in the event that your assessment reveals you may have Dry eyes?

Yes

Please fill out the information below to get your results emailed to you.

Name

Phone

Time is Up!

Time's up