Emmetropia Mediterranean Eye Institute

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Am I suitable ?

In order to be suitable for refractive surgery there are certain requirements:

  • You must be at least 18 years old and the degree of your refractive error must be steady for at least a year.
  • There should be no chronic disorders of the retina or cornea or other ophthalmological illnesses or inflammation.
  • If you are a woman, refractive surgery is to be avoided during pregnancy or nursing.
  • The pre-operative check will determine whether you can be subjected to laser treatment in the event that you fulfill all anatomical and optical conditions.

Personal data >

First name:

Last name:

Email:

Occupation:

Date of birth:

What frustrations do you currently have that relate to not being able to see as well as you like ?

List three or four of the reasons why you are now considering a vision correction procedure?

Please share with us some of the physical activities that you hope to further participate in after your procedure?

What restrictions do you have now because of your use of contacts or glasses?

What activities will you be able to more fully participate in after your vision is corrected?

Have you visited our website?

What led you to make an appointment with us?

If you were referred to us, who referred you?

Glasses >

1. What are your prescription details:

SPH CYL AXIS
OD (RIGHT EYE)DD
OS (LEFT EYE)DD

2. How often do you wear eyeglasses or contact lenses for distance vision?

3. Do you need eyeglasses for reading?

4. Do you currently wear contact lenses? (if no, skip to 6)

5. What kind of contact lenses do you wear now?

Ocular history >

7. List all eye surgeries you have had. Indicate which eye and the date of surgery

8. List all other surgeries you have had, with dates:

9. List eye injuries with dates:

10. List any eye diseases you have:

General Medical History >

Do you now or did you in the past have any of the following conditions

Atopic disease (if no, skip to 6)
Rheumatoid Arthritis (if no, skip to 6)
Autoimmune disease (if no, skip to 6)
Diabetes (if no, skip to 6)
Hepatitis (if no, skip to 6)
HIV infection (if no, skip to 6)
Keloid formation (if no, skip to 6)
Other medical problems (if no, skip to 6)

*If yes, please specify

List all eye drops you use, which eye, and how often you use them:

List all other medications you take with dosage and frequency:

List any medications you are allergic to:

If female, are you or might you be pregnant?

If female, are you trying to become pregnant?

Family medical history >

List any diseases that run in your family:

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