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  1.                                                                   INITIAL EXAM                                    EXCIMER LASER STUDY                            ╔═════════════════════════════════════════╦════════════════════════════════╗   ║                                         ║                            None║   ║Date ___/___/___     Chart # _________   ║ Syst. Meds:                  ■ ║   ║      m   d   y                          ║                                ║   ║                                         ║ Eye Meds:                    ■ ║   ║Pt. _____________________ _______ ____   ║                                ║   ║         Last              First  M.I.   ║ Syst. Ds:                    ■ ║   ║                 - - - - - Race - - - - -║                                ║   ║DOB:___/___/___  Cauc.___ Blk___ Other___║ Eye Ds:                      ■ ║   ║     m   d   y                           ║                                ║   ║- Gender -                               ║ Allergies:                   ■ ║   ║M___ F___ Investigator:__________________║                                ║   ╠═════════════════════════════════════════╩──────────┬─────────────────────╢   ║                                                    │Tension: None:OD■ OS■║   ║Visual Acuity:      Correction with:          Not   │   OD:_____ OS:_____ ║   ║        Uncorr.   Specs.    CLS    CLS+PH    done   │                  Not║   ║    OD: _______  _______  _______  ______      ■    │Mod.Trans.f(x):  done║   ║                                                    │   OD:_____        ■ ║   ║    OS: _______  _______  _______  ______      ■    │   OS:_____        ■ ║   ╠════════════════════════════════════════════════════╡            Obs.     ║   ║Objective Refraction:     Not done: OD ■  OS ■      │Pachymetry: init.    ║   ║                    Obs. Vertex     with CLS        │  1st.____mm ___   ■ ║   ║     Sph. Cyl. Ax.  init  (mm)    Sph. Cyl. Ax.     │  2nd.____mm ___   ■ ║   ║                                                    │                     ║   ║ OD:                                                │Axial Length:        ║   ║                                                    │   OD:____ mm      ■ ║   ║                                                    │   OS:____ mm      ■ ║   ║ OS:                                                │               Obs.  ║   ║                                                    │Ks:            init  ║   ║Manifest Refraction:      Not done: OD ■  OS ■      │OD:             __ ■ ║   ║                                                    │                     ║   ║ OD:                                                │OS:             __ ■ ║   ║                                                    │                     ║   ║                                                    │                     ║   ║ OS:                                                │ Mires:   ■Not done  ║   ║                                                    │    ■Good ■Distorted ║   ╠══════════════════════════════════════════╤═════════╧═════════════════════╣   ║Slit lamp exam:       Not done: OD ■  OS ■│                        No data║   ║                                          │ Pupils:                     ■ ║   ║                                          │                               ║   ║                                          │ EXT:                        ■ ║   ║                                          │                               ║   ║                                          │ EOM:                        ■ ║   ║                                          │                               ║   ║                                          │ VF:                         ■ ║   ║OD:                  OS:                  │                               ║   ╠══════════════════╤═══════════════════════╧═══════════════════════════════╣   ║Lens:      No data│Posterior Pole:    No data                      No data║   ║ OD:            ■ │ Optic nerve:           ■   Vitrious:                ■ ║   ║                  │                                                       ║   ║                  │                            Vessels:                 ■ ║   ║ OS:            ■ │ Macula:                ■                              ║   ║                  │                            Periphery:               ■ ║   ║                  │                                                       ║   ╠══════════════════╧════════════════════╤══════════════════════════════════╣   ║Tests:        Yes  No  Why not??       │Notes:                            ║   ║ SL Photo     ___ ___ _________________│                                  ║   ║ Endo cell ct.___ ___ _________________│                                  ║   ║ CMS          ___ ___ _________________│     Investigator's signature     ║   ║                                       │    __________________________    ║   ╚═══════════════════════════════════════╧══════════════════════════════════╝