RLE or Cataract Pre-Op Eval. Form Fax to 303 554 5846 Date:___________ Co-Managing Doctor:_______________________ PATIENT INFORMATION Date of Birth:
OD
Patient Name Phone
M / F (circle)
Surgeon
Surgery Date
EXTERNAL
Chief Complaint Personal Medical History None Diabetes Asthma Rheum. Arthritis Medications (Please List) None Flomax Ocular History None Corneal Dis. Retinal Glaucoma RK Cataract Drug Allergies NKDA Codeine Sulfa ASA Eye Medications None Steroids NSAIDS Antibiotics
Lupus Sjogerens
ALK PRK LASIK Iodine PCN Tears Glaucoma
Eye: Frequency: Dom. Eye OD / OS Curr. Mono? Y / N Tear Film (osmolarity)
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/ BAT/PAM 20/ 20/ Reading with Mono Add VA @ Near OD+ 20/ OS+ 20/ IOP App or NCT? OD OS Pachymetry OD OS Keratometry (Or topography simK’s) OD (flat) x (axis) OS (flat) x (axis)
OS
OD
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 RLE CE w/ IOL Procedure Request Mono Eye: Sequence (check 1st) OD OS OU Normal Corneal Topography Abnormal Abnormal Consent Signed
Assessment: Plan: Doctor Signature:
OS