Contact

The Eye Care Institute Building
Phone: (502) 589-1500 or
(800) 999-3036

Audubon Medical Plaza West
Phone: (502) 637-3036

Would you say your eyesight (with glasses or contacts, if you wear them) could be improved?	Yes	No
Do you have, or have you had, pain or discomfort in and around your eyes?	Yes	No
Do you have difficulty reading ordinary print?	Yes	No
Do you have difficulty reading street signs or the names of stores?	Yes	No
Do you have difficulty going down stairs and steps?	Yes	No
Do you have difficulty in noticing objects off to the side while walking alone?	Yes	No
Do you see halos or starbursts while driving at night?	Yes	No
Do you accomplish less than you would like because of your vision?	Yes	No
Are you limited in how long you can work, or do other activities, because of your vision?	Yes	No
Has you vision changed in the past year?	Yes	No
If you are over 40, do you have an annual dilated eye exam?	Yes	No
Do you have a family history of glaucoma, diabetes or macular degeneration?	Yes	No
Have you ever considered LASIK?	Yes	No

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