home *** CD-ROM | disk | FTP | other *** search
/ Magnum One / Magnum One (Mid-American Digital) (Disc Manufacturing).iso / d3 / formgen.arc / EXCPOST.FRM < prev    next >
Encoding:
Text File  |  1990-01-25  |  4.5 KB  |  1 lines
  1.    POSTOPERATIVE EXAM                                   Operative eye:  OD  OS                              EXCIMER LASER STUDY                                  ╔════════════════════════════════╤═════════════════════════════════════════╗   ║Date ___/___/___ Chart #________│Eye Meds:             Y N       Y x/d N  ║   ║      m   d   y                 │       Pressure patch ■ ■   Dec ■ __  ■  ║   ║                                │      Collagen shield ■ ■  Gent ■ __  ■  ║   ║Pt. _______________ _______ ____│Pain (Dr's score:0-10)__ Tyl #3 ■ __  ■  ║   ║         Last        First  M.I.│Other (list)______________________ __x/d ║   ╠════════════════════════════════╧══════════════════╤══════════════════════╣   ║Visual Acuity:        Correction with:        Not  │Tension: None:OD■ OS■ ║   ║        Uncorr.   Specs.    CLS     CLS+PH   done  │ OD:_____ OS:_____    ║   ║                                                   │                   Not║   ║    OD: _______  _______  _______  _______     ■   │Mod.Trans.f(x):   done║   ║                                                   │ OD:_____           ■ ║   ║    OS: _______  _______  _______  _______     ■   │ OS:_____           ■ ║   ╠═══════════════════════════════════════════════════╡            Obs       ║   ║Objective Refraction:       Not done: OD ■  OS ■   │Pach:       init      ║   ║                    Obs. Vertex   with CLS         │ 1st.___mm  ___     ■ ║   ║     Sph. Cyl. Ax.  init  (mm)  Sph. Cyl. Ax.      │ 2nd.___mm  ___     ■ ║   ║                                                   │                      ║   ║ OD:                                               │Axial Length:         ║   ║                                                   │ OD:_____ mm        ■ ║   ║ OS:                                               │ OS:_____ mm        ■ ║   ║                                                   │               Obs.   ║   ║Manifest Refraction:        Not done: OD ■  OS ■   │Ks:            init.  ║   ║                                                   │1.               __ ■ ║   ║ OD:                                               │2.               __   ║   ║                                                   │                      ║   ║ OS:                                               │Mires:   ■Not done    ║   ║                                                   │   ■Good ■Distorted   ║   ╠═══════════════════════════════════════════════════╧══════════════════════╣   ║SLE:      Not done ■     Epi defect?? (Y / N). If Y, % of ablated zone __ ║   ║                         Is ablation apparent?? (Y / N), edge?? (Y / N)   ║   ║                         Amount of edge ___ - ___o'c & ___ - ___o'c, or   ║   ║                         360 degrees___.  DM folds?? 0 1 2 3 4.           ║   ║                                                                          ║   ║                                                   CLARITY:               ║   ║                                            Epithelium     Stromal        ║   ║                                            Super. Deep   Ant. Post. Endo ║   ║Clear, possibly with faint spots . . . . . 0 ____  ____   ____ ____  ____ ║   ║Mild reticulated haze, not effecting Rfx . 1 ____  ____   ____ ____  ____ ║   ║Moderate haze, Rfx possible but difficult. 2 ____  ____   ____ ____  ____ ║   ║Opacity prevents Rfx, AC easily viewed . . 3 ____  ____   ____ ____  ____ ║   ║Opacity impairs view of AC . . . . . . . . 4 ____  ____   ____ ____  ____ ║   ║Unable to see AC . . . . . . . . . . . . . 5 ____  ____   ____ ____  ____ ║   ╠═══════════════════════════════════════╤══════════════════════════════════╣   ║     Unc. Worse??(describe)     No data│Notes:                            ║   ║Lens: ■  _______________________    ■  │                                  ║   ║O.N.: ■  _______________________    ■  │                                  ║   ║Ret:  ■  _______________________    ■  │                                  ║   ║Ves:  ■  _______________________    ■  │                                  ║   ║Mac:  ■  _______________________    ■  │                                  ║   ╠═══════════════════════════════════════╡                                  ║   ║Tests:        Y N  Why not??           │                                  ║   ║ Sl photo     ■ ■ _____________________│                                  ║   ║ Endo cell ct ■ ■ _____________________│      Investigator's signature    ║   ║          CMS ■ ■ _____________________│   _____________________________  ║   ╚═══════════════════════════════════════╧══════════════════════════════════╝