PA - CATARACT POST-OPERATIVE ASSESSMENT

CATARACT POST-OPERATIVE ASSESSMENT
SightMD PA Cataract Co-Management*

SightMD PA Cataract Co-Management
Patient Name*

First NameLast Name
Patient DOB*

MonthDayYear
Date
OD Procedure Date

MonthDayYear
Date
OS Procedure Date

MonthDayYear
Date

Procedure Information

	Procedure
OD
OS

Co-Managing Doctor Name*
Co-Managing Doctor Email*
example@example.com
Co-Managing Doctor Phone Number*
Please enter a valid phone number.
Co-Managing Doctor Fax Number*
Please enter a valid phone number.
SightMD Surgeon*
Post Op Dates

Post Op Dates

	Number	Day/Week/Month
OD
OS
Responsiveness
Friendliness

Visual Acuity (Uncorrected) : OD - 20/OS - 20/
Intraocular Pressure (mmHg) : OD - OS -
blanksblank
Manifest Refraction : (1 Month post op appt*)
OD - (SPH)blanks (CYL) blank X (AXIS) (Acuity) 20/
OS - (SPH) (CYL) X (AXIS) (Acuity) 20/

Slit Lamp - Wound*

	Observation	Comments
OD
OS

Cornea*

	Observation	Comments
OD
OS

Anterior Chamber*

	Observation	Comments
OD
OS

IOL*

	Observation	Comments
OD
OS

Posterior Capsule*

	Observation	Comments
OD
OS

Retina*

	Observation	Comments
OD
OS

Medications/Dosages - OD:*

	Medication	Dosage
Antibiotic
Steroid
NSAID
Other

Medications/Dosages - OS:*

	Medication	Dosage
Antibiotic
Steroid
NSAID
Other

Assessment/Comments:
Appointment made for patient with Dr. First Name Last Name on Date at Location
Additional Instructions for Patient:
File Upload

Cancelof
Examining Doctor
Date

MonthDayYear
Date
PATIENTS MAY BE REFERRED BACK TO THEIR SURGEON AT ANY TIME AND FOR ANY REASON. IF THE PATIENT FAILS TO KEEP THEIR APPOINTMENT, PLEASE CALL US AT 855.295.4144 WITHIN 24 HOURS OF A MISSED EXAM. PLEASE RETAIN A COPY FOR YOUR RECORDS
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