San diego eye bank excimer laser center

Patient Information
Patient Information
Name:______________________________________________________________ Date of Birth:________________ Address:_____________________________________________________________ Sex:________________________
Medical History Exam Date:_________________
If your patient has any of the following conditions or is

Known allergies: _____________________________________ taking any of the listed medications, please circle.

Keratoconus, Collagen Vascular Disease, Autoimmune, Positive medical or surgery history: ______________________ Immunodeficiency Disease, Pregnant or Nursing, Taking
Previous ocular surgery (OD, OS, OU): _____________________ Cordarone or Accutane

_______________________________________________________
Pre-Operative Information - OD
Pre-Operative Information - OS
Corneal haze: _________________ VA-sc: _______ VA-cc: ________
Corneal haze: _________________ VA-sc: _______ VA-cc: ________ Dominant Eye: ____Yes ____ No
Dominant Eye: ___ Yes ____No
Slit lamp exam: Normal / Abnormal Dilated exam: Normal / Abnormal
Slit lamp exam: Normal / Abnormal Dilated exam: Normal / Abnormal
Pentacam/Topography: Normal / Abnormal Pachometry: _________
Pentacam/Topography: Normal / Abnormal Pachometry: _________
Diagnosis: Myopia / Hyperopia / Ast / Mixed / ____________________
Diagnosis: Myopia / Hyperopia / Ast / Mixed / __________________
Keratometry: K1________AXIS______ K2_________AXIS_______
Keratometry: K1________AXIS_______ K2________AXIS______
Correction
Correction
Desired:
Desired:
WaveScan
WaveScan
Refraction:
Refraction:
WaveScan
WaveScan
Physician adj:
Physician adj:
WaveScan Nomogram Adj.:___________
WaveScan Nomogram Adj.:___________
Correction: (Circle all that apply)
Correction: (Circle all that apply)
PTK / PRK / LASIK / LASEK / CUSTOM / RETREAT / FLAP LIFT ONLY
PTK / PRK / LASIK / LASEK / CUSTOM / RETREAT / FLAP LIFT ONLY Vertex Distance: 12.50 / ______mm Hertz: 8 10 ________
Vertex Distance: 12.50 / ______mm Hertz: 8 10 ________
Blend Zone: Y N Ablation Zone: 6 / 6.5 / Hyp / Custom
Blend Zone: Y N Ablation Zone: 6 / 6.5 / Hyp / Custom
PRK: Alcohol / Brush / Laser Scrape MITO: ____ Yes ____ No
PRK: Alcohol / Brush / Laser Scrape MITO: ____ Yes ____ No
Plate: 160 / 180 / 200 / _____ Ring: 8.5 / 9.5 / 8.5M / 9.5M
Plate: 160 / 180 / 200 / _____ Ring: 8.5 / 9.5 / 8.5M / 9.5M
Intralase: Depth: ___________ Diameter: ________________
Intralase: Depth: ___________ Diameter: ________________
ALL AREAS MUST BE COMPLETED IF APPLICABLE PRIOR TO SURGERY
Physician’s Signature:_____________________________________ Physician’s Phone:_________________ Established: 4/96 Revised: 7/97, 1/98, 6/98, 6/99, 8/99, 9/99, 9/00, 7/01, 3/02, 5/02, 7/03, 9/04, 12/04, 2/05, 8/06, 10/09: NB, 3/12: ES, 8/13:NB Patient Information
Standard PRK, LASIK, LASEK or PTK All areas need to be completed except for WaveScan refraction, WaveScan physician adj and WaveScan completed: Y or N All areas need to be completed, however when entering in the treatment, complete only WaveScan refraction or WaveScan physician adj. Do not use Correction Desired. Established: 4/96 Revised: 7/97, 1/98, 6/98, 6/99, 8/99, 9/99, 9/00, 7/01, 3/02, 5/02, 7/03, 9/04, 12/04, 2/05, 8/06, 10/09: NB, 3/12: ES, 8/13:NB

Source: http://www.sdeb.org/pdf/FExc-014PatientInformation_Final_8-1-13.pdf