LVC Pre-Op Evaluation Form Fax to 303 554 5846 Date:___________ Co-Managing Doctor:_______________________ PATIENT INFORMATION Date of Birth: Patient Name Phone
M / F (circle)
Surgeon
Surgery Date
Chief Complaint Oral Meds Personal Medical History None Diabetes Lupus Asthma Rheum. Arthritis Sjogerens Ocular History None Corneal Dis. ALK Retinal Glaucoma PRK RK Cataract LASIK Present Correction Glasses CL (circle): Soft / RPG / PMMA Hrs/Day Worn: Years Worn: Last Worn: Drug Allergies NKDA Codeine Iodine Sulfa ASA PCN Eye Medications None Steroids Tears NSAIDS Antibiotics Glaucoma Eye: Frequency: Dom. Eye OD / OS Curr. Mono? Y / N Schirmers OD (mm) OS (mm)
CLINICAL DATA Va cc (distance) OD 20/ OS 20/ Present Glasses OD x Add OS x Add Distance Va sc OD 20/ Near w/ Dist RX Va sc OS 20/ Manifest Refraction BCVA OD x 20/ OS x 20/ Cycloplegic Refraction BCVA OD x 20/ OS x 20/ Reading with Mono Add VA @ Near OD+ 20/ OS+ 20/ IOP App or NCT? OD OS Keratometry (Or topography simK’s) OD (flat) x (axis) OS (flat) x (axis)
OD
OS
EXTERNAL
OD
OS
Normal Chalazion Blepharitis Conjunctiva Normal Abnormal Cornea Normal Dry Eye Dystrophy Vascularization Keratoconus Stromal scar Guttata 4-8 incision RK >8 incision RK AK PRK ALK LASIK Anterior Seg Clear (circle) +1 +2 +3 +4 OD Cell/flare (circle) +1 +2 +3 +4 OS Cell/flare Iris Normal Angle closed Pi Ti defects Lens Status Clear NS cataract PSC cataract Cortical cataract PC / AC / IOL Vitreal Status Normal PVD Cells Hemorrhage Retinal Status Normal Abnormal Lattice degen C/D Other PTK PRK LASIK Procedure Request Mono Eye: Sequence (check 1st) OD OS OU Normal Corneal Topography Abnormal Abnormal Consent Signed
Assessment: Plan: Doctor Signature: Peter Lehmann OD
Craig Beyer DO
Richard Stewart MD