opto1b




	Video Presentation


	Preoperative Refractive Examination

Patient Name:

M:

F:

DOB:

Age:

Referred by:

Occupation

HPI

Exam Date

Contacts

Hard

Soft

Date Last Worn

Hobbies

Past Ocular History

Medications

Medical History

Allergies

NKDA

Other

Ocular Dominance

OD

OS


	OD

UCVA

J

Spec RX

20

Pupils

MR

20/

Trial Frame 1

Trial Frame 2

BAT

CR

20

K readings

Corneal Diam

Topography

Done

IOP

mmHg

Pachymetry

u

E.P.T.

Lids/adnexa

Conj

Cornea

AC

Iris

Lens

Fundus

Special Needs


	OS

UCVA

J

Spec RX

20

Pupils

MR

20/

PERRLA

APD

Trial Frame 1

Likes

Dislikes

Trial Frame 2

Likes

Dislikes

BAT

CR-gtts:

20

K readings

Corneal Diam

Topography

Done

IOP

mmHg @

Pachymetry

u

E.P.T.

Lids/adnexa

Conj

Cornea

AC

Iris

Lens

Fundus

Special needs

Informed Consent: Discussed potential risks and benefits including:

Surgery Date

Surgeon


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