mavit
Modern Ophthalmology Clinic

Diagnostic-surgical Center
61 Podlesna St.
01-673 Warszawa (Warsaw), Poland
Ph. +48 22 569 59 00

Diagnostic Center
4 Migdalowa St.
02-796 Warszawa (Warsaw), Poland
Ph. +48 22 645 12 13

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Laser Vision Correction - Candidate's questionnaire

Below we provide a questionnaire which purpose is to determine whether you might be a good candidate for laser vision correction.
After filling out and sending the questionnaire, within few days you will receive an answer or additional questions from us.
This questionnaire has only an indicatory character and does not eliminate the need of performing full preliminary examination. But we hope that it might help to spare your precious time.
Podstawowe dane





woman man
* obligatory fields
Eye-sight defect (in diopters)
 Left eyeRight eye
Nearsightedness (-)
Farsightedness (+)
Astigmatism (please input by the value a + or - sign)

Has your eye-sight defect been stable for at least 1 year?
 YES  NO  I DON'T KNOW

If you know, please enter how many rows you see in the best correction on the Snellen chart (BSCVA i.e. best spectacle-corrected visual acuity):


Explanation: A person with good eyesight sees 10 rows without glasses
What do you usually use to improve your eye-sight?:





Which of the diseases do you suffer / did you suffer? diabetes
YES NO I DON'T KNOW

connective tissue diseases (collagenoses) - e.g. rheumatoid arthritis, sclerodermia, lupus, polyarteritis nodosa, psoriasis, or Sjogren's syndrome
YES NO I DON'T KNOW

auto-immune diseases
YES NO I DON'T KNOW

immunosupression related diseases
YES NO I DON'T KNOW

atopy and severe allergy
YES NO I DON'T KNOW

rosacea
YES NO I DON'T KNOW

active infectious diseases
YES NO I DON'T KNOW

indivdual tendency to form hyperplastic scars (keloids)
YES NO I DON'T KNOW

Do you have a cardiac pacemaker implanted?
YES NO
Has your doctor diagnosed any of the diseases mentioned below? keratitis
YES NO I DON'T KNOW

zoster ophthalmicus
YES NO I DON'T KNOW

glaucoma
YES NO I DON'T KNOW

cataract
YES NO I DON'T KNOW

retina detachment or degeneration
YES NO I DON'T KNOW

keratoconus
YES NO I DON'T KNOW

other cornea degenerations
YES NO I DON'T KNOW

hypolacrimation ("dry eye")
YES NO I DON'T KNOW

eye vascular diseases
YES NO I DON'T KNOW

severe degenerative myopia
YES NO I DON'T KNOW

nystagmus
YES NO I DON'T KNOW

strabismus (squint)
YES NO I DON'T KNOW
Additional information or comments: If you chose positive answer by any of the questions regarding diseases, pls. be so kind and provide more details about it in the field below.


Are you pregnant or breast-feeding?
YES NO I DON'T KNOW

We would be grateful for information about from where did you get information about Medical Center MAVIT (e.g. friends, title of magazine etc.)


If you want us to contact you by phone in order to make an appointment in case that the questionnaire results would be positive, pls. enter your full phone number below:


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