Medical Necessity For Cataract Surgery Form (Page 2 of 3) in pdf

Medical Necessity For Cataract Surgery Form Page 2

Name____________________________________

Date_______________

Quality of Vision Assessment

At Vista Eye Specialists, we strive to provide the best quality of care and customized

vision solutions for our patients. This form will assist us in helping you to choose the

treatment best suited for your visual needs and lifestyle. Please fill this form out

completely and return it to the receptionist. If you have any questions please let us know,

and we will be happy to assist you.

What are your favorite hobbies?

__________________________________________________________________

If you work, what are some of your daily work-related tasks?

__________________________________________________________________

Do you currently wear glasses? ____Yes ____No

If you currently wear glasses, for which activities do need them?

_____Near _____ Distance _____ Both

How important would it be for you to be free from glasses for your daily activities?

_____ Very important ____Moderately important ____Not important

If you could have good distance vision during the day without glasses and good near

vision without glasses, but the compromise was that you might see some halos around

lights at night, would you accept the compromise? ____Yes

____No

Which activity would bother you most to wear glasses?

____Reading fine print

_____Computers

_____Driving

If you had to wear glasses after surgery for one activity, for which activity would you be

most willing to use glasses? ____Reading fine print _____Computers ____TV / Driving

Are you willing to pay an out-of-pocket charge if it means less dependence on glasses?

____Yes ____No

How would you describe your personality?

_____ Easy going _____ Perfectionist _____ In between

It is important that you understand and remember that many people still need to wear

glasses for some activities after surgery.

Patient Signature _________________________________

Medical Necessity For Cataract Surgery Form Page 2