Vision/Lifestyle Questionnaire
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- Melvin Simpson
- 6 years ago
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1 Roger J. Meyer, M.D. Retina Fellowship Trained Macular Degeneration Diabetic Eye Care Glaucoma Robert M. Reinauer, M.D. Retina Fellowship Trained Surgical/Medical Treatment of the Retina & Vitreous Macular Degeneration Diabetic Eye Care Paul V. Minotty, M.D. Cataract Surgery David J. O Brien, M.D. Fellowship Trained Refractive Surgeon Eyelid Surgery Aesthetics Stephen M. Tate, M.D. Cataract Surgery Vision/Lifestyle Questionnaire Name Date of birth In addition to gaining clearer vision after cataract surgery, patients today have more of a choice in their visual outcome. This is achieved by replacing the clouded natural lens of the eye with a new clear lens (IOL) that has prescription power specifically measured for the individual patient. Some lenses best correct at distance, some at near, some at both distance and near, and some for astigmatism. For these reasons, no one lens is right for every patient. Also, some lenses are an additional cost for the patient. Please help us to better understand your visual goals by answering the questions below. What is your occupation (present or former) and favorite hobbies? Have you ever worn contacts to correct one eye for distance and one eye for near? If yes, was it successful for you? Do you feel that dry conditions affect your vision? How do you feel about wearing glasses? (please check all that apply) I don't mind wearing glasses all day. I don't mind wearing glasses for reading /close work. I don't mind wearing glasses for TV/driving distances. I would like to greatly reduce dependence on glasses for both reading and far distance, even if there is an increased incidence of glare/halos and decreased contrast in certain lighting conditions. Would you be willing to pay an out-of-pocket expense for a lens that compensates for astigmatism, if needed? Would you be willing to pay an out-of-pocket expense for a lens that decreases some of your dependence on glasses for near/reading and far distances, if you are a candidate? th Place Vero Beach, FL (772) Fax (772) MINOTTY
2 Frequently Asked Questions About Cataracts What is a cataract? A cataract is a clouding of the natural lens of the eye (which is located behind the pupil and iris). What causes a cataract? Though cataracts can occur at any age, most cataracts develop when aging or trauma cause proteins within the lens to break down and become cloudy or opaque. Less often, cataracts develop before birth, by use of corticosteroids, or by an inherited disorder. Prolonged exposure to sunlight and smoking may contribute to cataracts. Do cataracts ever go away on their own? No, the only treatment is surgery. Can cataracts be prevented? Though there is no certain prevention known, there are possible steps that a person could take in attempts to help prevent them. Wearing protective eyewear, when active, can aid against trauma. Wearing 100% UV protective sunglasses can aid against sun exposure. Avoiding smoking can aid in avoiding cellular oxidization. How fast do cataracts grow? There is a great variability. Some take years to change, while others change in a few months. Can cataracts develop in only one eye? Yes. How long does cataract surgery take? Generally minutes. Is anesthesia used for cataract surgery? Patients generally receive some sedation and the eye is numbed with eye drops. No needles are used and general anesthesia is not necessary. Are both eyes operated on the same day? No. The second eye is done when the first eye is safely out of the post-operative period. How long is the recovery time? This varies from a few weeks to longer in certain individuals. Normal activity generally resumes very shortly after surgery. Do cataracts come back after surgery? No, and the new lens stays clear. There is a normal clear membrane which is behind the lens called the posterior capsule. In some patients, the membrane may become cloudy in time. In this case, a simple laser procedure treats the cloudy membrane. Will my glasses be changed after surgery? Generally, yes.
3 ROGER J. MEYER, M.D. retina fellowship trained macular degeneration - diabetic eye Care glaucoma ROBERT M. REINAUER, M.D. retina fellowship trained SurgiCal/mediCal treatment of the retina & VitreouS macular degeneration diabetic eye Care NEW VISION EYE CENTER PAUL V. MINOTTY, M.D. CataraCt Surgery general ophthalmology - glaucoma NEW PATIENT INFORMATION SHEET DAVID J. O BRIEN, M.D. fellowship trained refractive Surgeon general ophthalmology - glaucoma eyelid Surgery - aesthetics STEPHEN M. TATE, M.D. - CataraCt Surgery general ophthalmology - glaucoma Patient Name: Local Address: Alternate Address: What months are you at your alternate address? From To Local Phone: Alternate Phone: Cellular Phone: Address: Patient Employer: Employer Phone: Patient Date of Birth: Sex: M F Patient SS#: Emergency Contact: Marital Status: Emergency Contact Phone: Spouses Name: Spouse s DOB: (If Minor) Parent Name: DOB: Daytime Phone: Driver s License Number: State: The information below is required for Electronic Medical Records: Pharmacy Name and Location: Preferred Language: Ethnicity: Not Hispanic or Latino Hispanic or Latino Race: Asian Black or African American White American Indian or Alaska Native Native Hawaiian or Other Pacific Islander INSURANCE INFORMATION Primary Insurance: Secondary Insurance: ID#: ID #: Please give cards to receptionist to make copies. Thank you. Which Doctor are you here to see? How did you hear about us? Please include names. TV / Channel Patient Insurance Company Family Member Seminar Referred by M.D. Our Website Optometrist Senior Services Guide Newspaper - Name Yellow Pages Radio - Station Name Other - Please Specify Please indicate the reason for your visit. Routine Eye Exam Diabetic Exam Interest in Laser Vision Correction Cataract Check Glaucoma Check Need New Glasses Having a Problem - Medical Skin Care Other DO NOT WRITE BELOW THIS LINE - FOR OFFICE USE ONLY City / State / Zip City / State / Zip Account Number: Date Registered: Registered By: Earning trust, one patient at a time. (772) Fax (772)
4 Roger J. Meyer, M.D. Retina Fellowship Trained Macular Degeneration Diabetic Eye Care Glaucoma Robert M. Reinauer, M.D. Retina Fellowship Trained Surgical/Medical Treatment of the Retina & Vitreous Macular Degeneration Diabetic Eye Care Paul V. Minotty, M.D. Cataract Surgery David J. O Brien, M.D. Fellowship Trained Refractive Surgeon Eyelid Surgery Aesthetics Stephen M. Tate, M.D. Cataract Surgery Please read the following Payment Policies before your appointment. Our office files your insurance as a "courtesy" lf your Doctor is an in-network provider for your insurance, YOUR COPAY MUST BE PAID AT THE TIME OF SERVICE ALL DEDUCTIBLES ARE DUE AT THE TIME OF YOUR VISIT. Please note - Each insurance policy is different. It is your responsibility to know your policy. lf pre-authorization is needed, then it is your responsibility to notify our staff so we may obtain authorization. lf authorization is not obtained, it is your responsibility to pay for all charges incurred. Remember, your insurance policy is a contract between you and your insurance company. lt is not a contract between you and our Doctors. ln order for us to process your insurance, we must have a copy of the card. It is also your responsibility to let us know if there is a change in your insurance information. lf you have any questions or are not prepared to pay for your appointment, please notify one of our office staff prior to your appointment. lf you are unable to pay for residual balances from previous dates of service you may be asked to reschedule your appointment. There is a $10.00 charge for NSF checks. We do not participate with any HMO plans. *Self pay patients are expected to pay in full at time of service. Signature Print Name Date (By signing this document, I am stating that I have read and understand the above information) th Place Vero Beach, FL (772) Fax (772) MINOTTY
5 Roger J. Meyer, M.D. Retina Fellowship Trained Macular Degeneration Diabetic Eye Care Glaucoma Robert M. Reinauer, M.D. Retina Fellowship Trained Surgical/Medical Treatment of the Retina & Vitreous Macular Degeneration Diabetic Eye Care Paul V. Minotty, M.D. Cataract Surgery David J. O Brien, M.D. Fellowship Trained Refractive Surgeon Eyelid Surgery Aesthetics Stephen M. Tate, M.D. Cataract Surgery Patient Consent Form for Use and Disclosure of Protected Health Information By signing this Consent Form, you give us permission to use and disclose protected health information about you for treatment, payment, and healthcare operations except for any restrictions specified below to which we have agreed. Protected health information is individually identifiable information we create or receive, including demographic information, relating to your physical or mental health, to provision of healthcare services to you, and to the collection of payment for providing healthcare services to you. Our Notice of Privacy Policies provides information about how we may use and disclose protected health information about you. As provided in our Notice, the terms of the Notice of Privacy Policies may change. If we change our Notice, you may obtain a revised copy by contacting our information privacy official, the Administrator, Lindy MacDonald at , who is also available to respond to any questions or receive any complaints you may have concerning your protected health information. You have the right to request that we restrict how protected health information about you is used or disclosed for treatment, payment, or healthcare operations. We are not required to agree to any restrictions, but if we do, we are bound to our agreement. If you wish to make a restriction, please request a copy of our Form to Request Restrictions. If you do not sign this Consent Form, we have the right to refuse you treatment unless a licensed healthcare professional has determined that you require emergency treatment or we are required by law to treat you. We are required to document any circumstances in which we do not obtain your consent, yet carry out treatment. We will offer you a copy of this documentation should you decide not to sign this Consent Form. You have the right to revoke this consent, in writing, except where we have already made disclosures in reliance on your prior consent. You may request to use our Authorization for Release of Information for purposes of requesting your revocation, or you may simply send us a letter in writing. By signing this consent, you acknowledge that you have received a copy of the "Notice of Privacy Policies". Please list the names of additional people we may disclose your protected health information either by phone or documentation: Name Name Name Relationship to patient Relationship to patient Relationship to patient Patient s Signature Date th Place Vero Beach, FL (772) Fax (772) MINOTTY
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