LIFESTYLE COMPLAINTS TO ESTABLISH MEDICAL NECESSITY
Name
*
First Name
Last Name
Birthdate
-
Month
-
Day
Year
Date
Do you wear any of the following?
Prescription Glasses
Contacts
Reading Glasses Only
None
If you wear glasses or contacts, the following questions apply to your vision while wearing them.
Glare from bright lights, headlights, and / or sunlight make it difficult to drive.
*
Yes
No
I avoid driving at night because of glare from headlights and / or streetlights.
*
Yes
No
I no longer drive because of poor vision and difficulties with glare.
*
Yes
No
Fluorescent lights makes reading, shopping, and/or other functions difficult.
*
Yes
No
I have difficulty reading small print because of decreased vision.
*
Yes
No
Blurred vision has made it difficult to do close-up work.
*
Yes
No
I have a hard time watching television because of decreased or blurred vision.
*
Yes
No
Blurred vision from sunlight makes it difficult to participate in outdoor activities.
*
Yes
No
Glare from sunlight makes it difficult to participate in outdoor activities.
*
Yes
No
Poor vision causes difficulty with many of my daily activities.
*
Yes
No
I have noticed an imbalance in the vision between my eyes.
*
Yes
No
Decreased or blurred vision has made it uncomfortable maneuvering stairs, curbs, and / or sidewalks.
*
Yes
No
What specific activity in your life has become difficult because of decreased, blurred, or glared vision?
Signature
*
Clear
Submit
Should be Empty: