REFRACTIVE SURGERY CONSULTATION FORM Name: _____________________________________________________________________ Date: ___________________________ Address: ___________________________________________________________________________________________________ City: __________________________________________________________ State: ______________ Zip: ____________________ Home Phone No.: ____________________ Work Phone No.: _______________________Other (cell): ______________________ Emergency name/number: _______________________________Home Email Address: __________________________________ Age: ______ DOB: _______________ Sex: ____________ Occupation: _______________________________________________ Employer: _________________________________________________________________________________________________ Routine Optometrist/Ophthalmologist: _____________________________ Family Physician ____________________________ Medical Insurance: __________________________________________________________________________________________ Do you wear Glasses? Yes (Distance Near Both) No Contact Lenses? Hard Soft GP Last Worn? _______________ How did you hear about us? ___________________________________________________________________________________ Newspaper (note which)________________________________ Patient referral (name)____________________________________ Direct mail/flyer (note which)____________________________ Health Fair/Seminar (note which)___________________________ If you are a good candidate for Vision Correction, how soon would you like to have the procedure? __________________ What has motivated you to consider Vision Correction? (Circle those that apply) Improvement of job performance
Fire/Rescue Law Enforcement Medical Other_____________________________________________________
Increased enjoyment of sports
Water Sports Skiing Jogging/Hiking Exercise/Aerobics Racquet Sports Golf
Other _____________________________________________
The least I expect from Vision Correction is: (Circle all that apply)
Meet job qualifications, which are: ___________________________________________
Do you have any other objectives or expectations from having the procedure? _________________________________________ ___________________________________________________________________________________________________________ Do you have any challenges with your night vision while wearing your glasses or contacts? Have you or do you intend to visit any other Laser Eye Centers or Doctors? YES NO If yes, which: _______________________________________________________________________________________________ (Turn Over) MEDICAL HISTORY Please check YES or NO if you have any of the following conditions: Diabetes Pregnant/Nursing or planning on becoming pregnant in next 3 months Rheumatoid Arthritis Pacemaker Psychiatric/Psychological Therapy/Depression Drug Allergies If yes, to what?_________________________________________________ Have you ever taken Amiodarone (Cordarone, Pacerone)? Have you taken Acutane (oral acne medication) within the last year? If yes, when did you stop taking it? ___________________________________________________________________________ Any other Existing Medical Problems:_________________________________________________________________________ List Medications you are currently taking: _____________________________________________________________________
OCULAR HISTORY Please check YES or NO if you have any of the following conditions: Past or present problems with contacts Ocular Infections? (Specifically Ocular Herpes) Previous Eye Surgery History of eye trauma History of Kerataconus (Chronic Progressive Thinning of the Cornea) Glaucoma Cataracts Retina Problems Eye Muscle Problems or history or eye muscle surgery Corneal erosion syndrome (from a prior corneal abrasion) Have you been told you are not a candidate for Laser Eye Surgery PREOPERATIVE EVALUATION Has your prescription changed significantly in the last year? Are you over 40 years of age? Have you had good vision all your life, until age 40? Do you dislike wearing or dealing with glasses? Do you remove your glasses to read? DRY EYE CHECKLIST Please check off any symptoms you have experienced with or without contact lenses. ____ Dry sensation ____ Scratchy, gritty feeling ____ Burning ____ Stinging ____ Lid infections ____ Soreness ____ Mucous discharge ____ Irritation from wind or smoke ____ Itching ____ Solution sensitivity ____ Tired eyes ____ Light sensitivity ____ Excessive tearing ____ Lens discomfort ____ Eyelids stuck in a.m.
Ärendeansvarig _________________________________________________________ Patientens personnr _________________ Namn _______________________________ Informationsdatum Vid det datum som anges ska övriga uppgifter som registreras varit gällande: __________________________ (ÅÅÅÅ-MM-DD) Ange aktuell puls. Vilopuls bör mätas efter två minuters vila och på aktuell enhet.
Collaborazione scientifica e tecnologica tra Cipro e Italia: bando per la raccolta di progetti di mobilità e per la segnalazione preliminare di iniziative rilevanti. stato pubblicato il "Bando per la raccolta di progetti di mobilità nell'ambito del Programma Esecutivo dicollaborazione scientifica e tecnologica tra ITALIA e CIPRO (2007-2009)". Beneficiari
REFRACTIVE SURGERY CONSULTATION FORM