Corporate Office | 653 Camino de los Mares #103 | San Clemente, Ca 92673
Mission Viejo Office | 26726 Crown Valley Pkwy #220 | Mission Viejo, CA 92691
Laguna Hills Office | 23521 Paseo de Valencia #306 | Laguna Hills, CA 92653
Additional Locations | Irvine | Costa Mesa | Big Bear | Lake Arrowhead
Phone: (949) 489-2218 | Fax: (949) 496-3604 | www.tayanieye.com
Dear Patient:
Thank you for your continued loyalty to our practice and for considering us for your eye
surgery. We have prepared this packet to educate you about the following items:
• What is Cataract?
• Cataract Surgery
• Lens implant options that will replace the cataractous lens in your eye
Please review and complete the following form before your appointment:
• Vision Lifestyle Questionnaire- this will allow us to make recommendations
regarding what options best suit your visual and lifestyle needs.
On the day of your appointment, be prepared to provide the following:
• Insurance Card
• Valid Picture Identification Card (Driver’s License, ID Card, etc)
• If you have insurance, you will be responsible for your co-pay.
o If you were referred by your primary care physician and your insurance
carrier requires a referral, please contact our office prior to your
appointment to ensure that we have received one.
• If you are a cash patient, you will be responsible for a payment for the initial
cataract consultation which includes all necessary tests.
o We gladly accept Visa, Mastercard, American Express, Discover, Personal
Checks and Cash.
Your appointment is on ____________________ at __________________
in the _________________________________ office.
Should you have any questions, please feel free to call us at (949) 489-2218. We look
forward to seeing you and appreciate you scheduling with The Tayani Eye Institute.
Sincerely,
Medical Staff
THE TAYANI EYE INSTITUTE
Vision Lifestyle Questionnaire Name: ____________________________________ Date: _______________________________ The term “cataract” refers to a cloudy lens within the eye. When a cataract is removed, a lens
implant is used to replace the cloudy human lens. If it is determined that a lens implant is
appropriate for you, your answers will help us select an implant that best suits the vision
demands of your lifestyle. (2 page questionnaire front and back)
1. Does wearing glasses bother or frustrate you?
Yes
No
2. If lens replacement is recommended for you; please rate your vision preferences at the
following distances?
Distance Vision: driving, golf, tennis, other sports, watching TV.
Prefer no distance vision glasses
I wouldn’t mind wearing distance glasses
Mid-range Vision: computer, menus, price tags, cooking, board games, items on a shelf.
Prefer no mid-range vision glasses
I wouldn’t mind wearing mid-range glasses
Near Vision: reading books, newspapers, magazines, doing detailed handwork.
Prefer no near vision glasses
I wouldn’t mind wearing near glasses
3. Please check the single statement that best describes you in terms of night vision:
Night vision is extremely important to me, and I require the best possible quality.
I want to be able to drive comfortably at night, but I would tolerate some slight imperfections.
Night vision is not important to me.
4. If you had to wear glasses after surgery for one activity, which activity would you be
most willing to use them for?
Distance Vision
Mid-range Vision
Near Vision
5. How many pairs of (reading and/or distance) glasses do you currently own? ___________
Continued on back….
Vision Lifestyle Questionnaire/ Tayani Eye Institute/ 12.8.10 AC
6 If you could
6.
c
have good distaance visionn during thhe day withhout glasses, and good near
vision for
f reading without gllasses, but the comprromise wass that you might see
e some
halos or
o rings arround ligh
hts at night,, would thaat be OK?
Yes
No
7 If you could
7.
c
have good distaance visionn and mid-rrange visioon during the
t day andd night
withoutt glasses, but the com
mpromise was
w that you might need
n
glas
sses for re
eading
the finest print at near
n visionn, would yoou like thaat option?
Yes
No
8 How ma
8.
any hours per day doo you spendd:
_______ On the computer
c
r
_______ Reading
g books, new
wspapers, typped documeents or small print
_______ Driving
9
9.
List your favoritee hobbies or work activities.
_______________
__
_________________
_________________
_______________
__
_________________
_________________
10. Please place an “X”
“ on the scale to de
escribe your
y
perso
onality ass best you can:
c
Easy
y going
Pe
erfectionis
st
Thank yoou for com
mpleting!
Pleasee be sure to
t bring th
his questioonnaire wiith you on
n your app
pointment date.