Medical Necessity For Cataract Surgery Form
ADVERTISEMENT
1
2
3MEDICAL NECESSITY FOR CATARACT SURGERY
Date
Date of Birth
Patient Name
Reason for exam today (patient words)
What specific improvements in your daily life do you hope to gain with surgery?
With Advanced Technology Implants, Vista Eye Specialists is able to offer you more visual freedom from
your distance and reading glasses after cataract surgery. Please print and fill out the additional forms in
the Pre Cataract Questionnaire section on our website to determine if you are a candidate for this
amazing technology.
Visual Functional Status (circle responses)
YES
NO
1) Do you have difficulty seeing street signs or to drive?
(curbs, freeway exits, traffic lights, halos/glare around lights).
YES
NO
2) Do you have difficulty seeing TV or movies?
(faces, numbers, or printing).
YES
NO
3) Do you have difficulty reading small print with good light, blinking
and proper glasses?
(books, newspaper, telephone book, medicine labels, instructions).
YES
NO
4) Do you have difficulty performing handiwork?
(sewing, knitting, crocheting, embroidery or other fine task)
YES
NO
5) Do you have difficulty with personal correspondences?
(writing checks, reading bills, filling out forms)
YES
NO
6) Do you have difficulty with leisure activities?
(playing card games, bingo, dominoes, or sport activities such as bowling,
hunting, golf, tennis, other _________________________________)
YES
NO
7) Do you have visual difficulty with navigation around the house?
(cooking, ironing, general household upkeep, climbing steps or curbs, dialing
the telephone, telling time on watch, using public transportation)
YES
NO
8) Are you able to see and recognize faces of people?
(in church, grocery store, clubs, and other daily activities?)
YES
NO
9) Are you able to care for yourself with your present vision?
Do you live alone and wish to remain independent?
Do you have any of the following VISUAL SYMPTOMS?
1) Double or distorted vision?
YES
NO
2) Glare, halos, rings around lights?
YES
NO
3) Difficulty with color perception?
YES
NO
4) Difficulty with depth perception?
YES
NO
5) Worsening of vision – blurred vision?
YES
NO
ADVERTISEMENT
0 votes
Related Articles
Related forms
Sample Letter Of Medical Necessity For Bariatric Surgery From The Fake Office Of Dr. Sample Mcsampleton (reference Only)
Letters
Medication Authorization For Cms Students Form/authorization For Self-medication By Cms Students Form - 2006
Medical
Related Categories
Parent category: Medical