POST PROCEDURE CARE - LASIK
SightMD PA POST PROCEDURE LASIK
SightMD PA POST PROCEDURE LASIK
Patient Name
First Name
Last Name
Co-Managing Doctor
First Name
Last Name
Co-Managing Doctor Email
example@example.com
Co-Managing Doctor Phone
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Co-Managing Doctor Fax
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SightMD Surgeon
*
Please Select
James Lewis, MD - Elkins Park
*
Procedure Date
Procedure Type
Original RX
Original BCVA: 20/
Age
Aim
Right Eye
Primary LASIK
Enhancement
Plano
Mono
Original RX
Primary LASIK
Enhancement
Plano
Mono
Exam Information
*
Exam Date
Post Op Type
Right Eye
Day 1
Week 1
Week 2
Week 3
Month 1
Month 2
Month 3
Month 6
Month 9
Month 12
Left Eye
Day 1
Week 1
Week 2
Week 3
Month 1
Month 2
Month 3
Month 6
Month 9
Month 12
*
PT Remarks
Right Eye
Left Eye
Meds
*
Meds
Meds (Cont)
Right Eye
Q 1hr
QID
TID
BID
QD
NiL
Q 1hr
QID
TID
BID
QD
NiL
Left Eye
Q 1hr
QID
TID
BID
QD
NiL
Q 1hr
QID
TID
BID
QD
NiL
UCVA
*
20/
Fluctuating Vision
Right Eye
Blurry
Glare
Double
Fluctuates
Left Eye
Blurry
Glare
Double
Fluctuates
Refraction
*
Auto Refraction
(Wet / Dry )
20/
Right Eye
Wet
Dry
Left Eye
Wet
Dry
LASIK Corneal Flap
*
Position
Clarity
Interface
Edges
Right Eye
Excellent
Dislodged
Striae
Clear
Edema
Haze
Clear
Opacities
Epi. ingrowth
Smooth
Rolled
Eroded
Left Eye
Excellent
Dislodged
Striae
Clear
Edema
Haze
Clear
Opacities
Epi. ingrowth
Smooth
Rolled
Eroded
IOP ( after 1 week/applanation):
*
mmHg
Right Eye
Left Eye
*
Doctor Comments
Enhancement
Follow Up
Right Eye
Excellent
Stable
Enhancement
Myopia
Hyperopia
Cylinder
Epithelial Ingrowth
Central Island
SightMD to contact patient
Patient will call SightMD
Left Eye
Excellent
Stable
Enhancement
Myopia
Hyperopia
Cylinder
Epithelial Ingrowth
Central Island
SightMD to contact patient
Patient will call SightMD
*
Treatment
Right Eye
Left Eye
Follow up
*
Follow Up
Next Visit in
Right Eye
with co-managing Doctor
with SightMD
1 week
2 weeks
3 weeks
1 month
2 months
3 months
4 months
5 months
6 months
Left Eye
with co-managing Doctor
with SightMD
1 week
2 weeks
3 weeks
1 month
2 months
3 months
4 months
5 months
6 months
Comments
Doctor Signature
*
Date
*
-
Month
-
Day
Year
Date
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