Keil Lasik General Questions Question Title * 1. Which of the following best describes you? Male Female OK Question Title * 2. Please enter your birthdate. Date Date OK Question Title * 3. What is your zip code? OK Question Title * 4. What is your marital status? Never married Married Widowed Divorced Separated I'd rather not say OK Question Title * 5. How many children (18 years of age or under) are living in your household? None 1 2 3 4 5+ OK Question Title * 6. What is the highest level of school you have completed, or the highest degree you have earned? Less than high school degree High school degree or equivalent (ie. GED) Some college but no degree Trade certificate Associate's degree Bachelor's degree Graduate degree OK Question Title * 7. What is your current employment status? Employed, full time Employed, part time Not employed, not looking for work Not employed, looking for work Retired Disabled, not able to work OK Question Title * 8. What is your approximate annual household income? $0 - $49,999 $50,000 - $99,999 $100,000 - $149,999 $150,000 - $199,999 $200,000 + OK Question Title * 9. In a typical week, how many days do you exercise or participate in sports? I don't regularly exercise Once per week 2-4 times per week 5-7 times per week OK Question Title * 10. On average, how often do you travel for pleasure? Weekly Monthly A few times per year Less than a few times per year OK Question Title * 11. In the past 12 months, which of the following hobbies have you participated in? (please select all that apply) Arts & Crafts Baking/Cooking Baseball/Softball Basketball Bicycling Boating Camping Fishing Football Gardening Golf Hiking Hockey Hunting Jogging/Running Motorcycling Music PC/Console Video Games Photography Sailing Skiing/Snowboarding Surfing/Windsurfing Soccer Swimming Tennis/Raquetball Weight Lifting Yoga None of the above OK Question Title * 12. Which social media networks do you regularly use? (please select all that apply) Facebook Instagram Snapchat Twitter LinkedIn YouTube Other OK Question Title * 13. What type of radio broadcasting do you listen to? (please select all that apply) None AM/FM Sirius/XM Pandora Spotify Internet or Streaming Apps OK Question Title * 14. What type of music/programming do you listen to? (please select all that apply) Talk Radio Country Pop Rock Classical Easy Listening Religious Sports Folk Reggae Electronic Rap/Hip Hop R&B Alternative/Indy Heavy Metal Bluegrass Other OK Question Title * 15. How do you watch television programming? (please select all that apply) Antenna Cable Satellite (ie. DirectTV or Dish) Internet or Video Streaming Apps I do not regularly watch television programming OK Question Title * 16. In the past year, which of the following sporting events have you watched in-person or on television? (please select all that apply) Basketball Football Baseball Boxing/MMA/Fighting Golf Tennis Soccer NASCAR Hockey Video Game Competitions I don't typically watch sporting events OK Question Title * 17. In the next 12 months, how are you most likely to spend your disposable income? (please select all that apply) Leisure Travel New Home or Home Improvement New Car Entertainment Savings or Investments Debt or Bills Self Improvement Procedure (ie. Laser Vision Correction, Tattoos, Botox, Liposuction or Plastic Surgery) Recreational Vehicles (ie. Motorcycle, RV, Boat) Large Appliances or Electronics Clothing/Jewelry Education Other OK Question Title * 18. Have you had any of the following? Tattoo(s) Piercings (Ears Only) Piercings (Other) None of the above OK Question Title * 19. Have you ever had any cosmetic or elective procedures? Yes No No, but I have considered it OK Question Title * 20. Do you regularly wear glasses or contacts? Glasses Contacts Both None OK Question Title * 21. Do you have an astigmatism? Yes No I don't know OK Question Title * 22. There are many myths about Lasik ... which ones have you heard? (please select all that apply) If you intend to have children, you should wait to have Lasik because your vision may change during pregnancy. If I am over 40, I am too old to have Lasik. Lasik is still a relatively new procedure so longterm side effects have not yet been discovered. Lasik is painful. Lasik is for near-sighted patients only. Lasik cannot correct an astigmatism. Permanent blindness is a potential Lasik complication. Lasik is not affordable. The effects of Lasik only last a few years. It takes a long time to recover from Lasik. None. OK Question Title * 23. Have you ever had or ever considered having Lasik? Yes, I have considered Lasik Yes, I have had Lasik No, I have not considered Lasik No, I have no interest in Lasik OK NEXT