Post-Op Evaluation Form Fax to 303 554 5846 Date of Exam: ________________
List Meds
PATIENT INFORMATION Patient Name Date of Birth Surgeon
CLINICAL FINDINGS
Chief Complaint
PROCEDURE OD
OS
OU
LASIK PRK CXL
FOLLOW-UP VISIT First (1-3 days) 1 week 1 month 3 month 6 month 1 year Unscheduled visit* *Reason:
CLINICAL DATA Distance Va sc OD 20/ PH 20/ Va sc OS 20/ PH 20/ Manifest Refraction BCVA OD x 20/ OS x 20/ Keratometry (Or topography simK’s) OD (flat) x (steep x steep axis) OS (flat) x (steep x steep axis) IOP App or NCT? OD mmHg OS mmHg
OD
Epithelium normal SPK Defect<2mm Defect 2-5mm Defect>5mm Haze 0 clear .5 trace 1 minimal 2 mild 3 moderate 4 marked Stroma 0 normal 1 1+edema 2 2+edema 3 3+edema 4 4+oredema 5 infiltrates 6 scarring Patient Symptoms F.B. Sensation Discomfort/pain Tearing Photophobia Visual fluctuation Glare
OD
OS
OD
OS
OD
OS
(rank 0-4)
Flap (LASIK) 0 normal 1 1+folds 2 2+folds 3 3+folds 4 edema Interface 0 normal 1 debris 2 neovasc. 3 pigment 4 deposits
OD
OS
OD
OS
Complications none Epithelial def. Corneal scar Corneal Infect. Cap thinning Other
OD
OS
OD
OS
Assessment: Plan: Doctor Signature: Craig Beyer DO
Copy to Surgeon:
Co-Managing Doctor:_____________________________
OS
PRESENT MEDICATION REGIME Patient Compliance
Yes
OD:
Y/N
OS: Y / N