SALEM LASER AND SURGERY CENTER
Patient Name
Date of Surgery
Surgeon
Marcus A. East, M.D.
Ryan W. Lapour, M.D.
John G. Dodd, D.O.
Primary Physician
PRE-OPERATIVE HISTORY & PHYSICAL
Click to Hide / Show Past History Options
Past Ocular History
OD PCIOL
OS PCIOL
OD Capsulotomy
OS Capsulotomy
OD Pterygium
OS Pterygium
OD LPI
OS LPI
OD Bleph
OS Bleph
OU Bleph
OU Bleph
OS Trabeculectomy
OD Trabeculoplasty
OS Trabeculoplast
OD SLT
Cataract
OD Cataract H25.11
OS Cataract H25.12
OD Cataract H25.811
OS Cataract H25.812
Capsulotomy
OD Capsulotomy H26.491
OS Capsulotomy H26.492
Iridotomy
OD Iridotomy H40.031
OS Iridotomy H40.032
SLT
OD SLT H40.11__
OS SLT H40.11__
Pterygium w/conj graft
OD Pterygium w/conj graft H11.___
OS Pterygium wconj graft H11.___
Pterygium w/amniotic graft
OD Pterygium w/amniotic graft H______
OS Pterygium w/amniotic graft H______
Ectropion
OD Ectropion H02.1__
OS Ectropion H02.1__
Entropion
OD Entropion H02.0__
OS Entropion H02.0__
Blepharoplasty
OD Blepharoplasty H02.831
OS Blepharoplasty H02.834
OU Blepharoplasty H02.831/H02.834
Ptosis repair
OD Ptosis RepairH02.4__
OS Ptosis repairH02.4__
OU Ptosis repair H02.4__
Trabeculectomy
OD Trabeculectomy H40.1__
OS Trabeculectomy H40.1_
Trabeculoplasty
OD Trabeculoplasty H40.___
OS Trabeculoplasty H40.___
Kahook Dual Blade
OD Kahook Dual Blade H
OS Kahook Dual Blade H
Retinal Detachment
Glaucoma
Macular Degeneration
Conjunctivitis
Floaters
Dry Eye Syndrome
Retinopathy
Diabetic Retinopathy
Cataracts
Blepharitis
Photophobia
Stabismus
Amplyopia
Diplopia
Uveitis
Madarosis
Drusen
Xerophthalmia
Retinitis
Retinitis Pigmentosa
Xeroderma
Ocular Hypertension
Ocular Migraine
Ocular Rosacea
Keratitis
Optic Neuropathy
Optic Neuritis
Keratoconus
Color Blindness
Macular Edema
Stye
Pterygium
Herpes Simplex Keratitis
Primary Juvenile Glaucoma
Dystrophy
Subconjunctival Hemorrhage
Chalazion
Stargardt Disease
Retinal Migrains
Corneal Abrasion
Corneal Ulcer
Allergies
Eye Infections
Hyphema
Macular Hole
Ptosis
Pinguecula
Cancer
Papilloma
Entropion
Ectropion
Heterochromia
Halos
Optic Nerve Trama
Eye Tumor
Graves Disease
Eye Trama
Past Medical History
Acute Laryngopharyngitis
Acute Maxillary Sinusitis
Afib
Allergic Rhinitis
Alzheimer's Disease
Anxiety
Arrhythmia
Arthritis
Asthma
Back Pain
Breast CA
Cerebrovascular Disease
Chronic Pain
Claustrophobia
Congestive Heart Failure
COPD
Coronary Atherosclerosis
Coronary Cancer
Cystic Fibrosis
Depression
Diabetes
Diverticulitis
Epilepsy
Fibromyalgia
Gastitis
Gastroesophageal Reflux
GERD
GORD
Gout
Headache
Head Injury
Hearing loss
Heart Disease
Heart Failure
Hypercholesterolemia
Hyperlipidemia
Hypertension
Hyperthyroidism
Hypocholesterolemia
Hypothyroidism
Joint Pain
Leukemia
Lung Cancer
Lupus
Lymphoma
Meningitis
Migraines
Motor Neuron Disease
Multiple Sclerosis
Myositis
Obesity
Osteoarthritis
Osteoporosis
Parkinson's Disease
Peptic Ulceration
Pneumonia
Prostate Cancer
Pulmonary Edema
Pulmonary Tuberculosis
Reflux Esophagitis
Respiratory Problems
Rheumatoid Arthritis
Septic Arthritis
Silent Heart Attack
Stroke
Thyroid Dysfunction
Tinnitis
Viral Hepatitis
Urinary Tract Infection
History of Present Illness
Aneurysm Repair
Appendectomy
Arrhythmia Treatment
Artificial Heart Surgery
Back Surgery
Breast Biopsy
Carpal tunnel
Carotid Endarterectomy
Cataract Surgery
Cesarean Section
Cholecystectomy
Colectomy
Colon Cancer Surgery
Coronary Artery Bypass
Free Skin Graft
Endarterectomy
Hemorrhoids Surgery
Heart Transplant
Heart Valve Repair
Heart Valve Replacement
Heart Surgery
Hemorrhoidectomy
Hernia Surgery
Hip Replacement
Hysterectomy
Hysteroscopy
Inguinal Hernia Repair
Knee Replacement-Right
Knee Replacement-Left
Laminectomy
Laparoscopic Cholecystectomy
Laparoscopic Nissen Fundoplication
Laparoscopic Ventral Hernia Repair
Low Back Pain Surgery
Lumpectomy L
Lumpectomy R
Lung Surgery
Mastectomy (Partial)
Mastectomy (Full)
Nephrectomy
Open-Heart Surgery
Pacemaker
Partial Colectory
Prostatectomy
Shunt Repair
Thyroidectomy
Thyroid Surgery
Tonsillectomy
Transmyocardial Laser Revascularization
Tubal Ligation
Vericose Vein Surgery
VINUS Closure
HPI:
PMHx:
POHx:
Patient has an implanted internal defibrillator
Reaction
REGULAR MEDICATIONS
DOSE
SCHEDULE
DRUG ALLERGIES
NAUSEA
VOMIT
RASH
SHOCK
OTHER
Every Day (QD)
Twice a Day (BID)
Three Times a Day (TID)
At Bedtime (QHS)
Every AM (QAM)
As Needed (PRN)
See Attached List
Tylenol
Combigan
Zaditor
latanoprost
fish oil
Flovent HFA
dorzolamide-timolol
durezol
prolensa
ciprofloxacin
Ventolin HFA
cyclobenzaprine
losartan-HCTZ
pravastatin
Tylenol Arthritis
Cialis
CoQ10
Caltrate
timolol maleate
ProAir HFA
Diphenhist
glipizide
benazepril
Jardiance
humulin
Victoza
Aspirin
B complex
zoloft
Vitamin A
Vitamin B12
Vitamin C
Vitamin D
Vitamin D3
acetaminophen
atorvastatin
hydrocodone and acetaminophen
amoxicillin
levothyroxine
escitalopram
montelukast
esomeprazole
simvastatin
clopidogrel
metoprolol succinate
azithromycin
cetirizine
ezetimibe and simvastatin
lisinopril
oxycodone and acetaminophen
warfarin
hydrochlorothiazide
furosemide
cephalexin
fluticasone/salmeterol
pantoprazole
amlodipine
lansoprazole
metoprolol tartrate
venlafaxine
alendronate
valsartan
sertraline
ezetimibe
rosuvastatin
metformin
quetiapine
levofloxacin
valsartan and hydrochlorothiazide
atenolol
pioglitazone
duloxetine
prednisone
tamsulosin
albuterol
celecoxib
insulin glargine
risendronate
alprazolam
mometasone
sildenafil
fenofibrate
ramopril
propoxyphene napsylate and acetaminophen
ethinyl estradiol and drospirenone
trazodone
risperidone
acetaminophen and codeine
estrogens, conjugated/equine
losartan
donepezil
clonazepam
paroxetine
carvedilol
zolpidem
amoxicillin and clavulanate
dextroamphetamine and amphetamine
amlodipine and benazepril
digoxin
fluticasone propionate
gabapentin
sulfamethoxazole and trimethoprim
valacyclovir
triamterene and hydrochlorothiazide
pregabalin
ibuprofen
rosiglitazone
topiramate
lamotrigine
methylphenidate
lorazepam
latanoprost
ethinyl estradiol and norgestimate
fluoxetine
potassium chloride
rabeprazole
varenicline
clonidine
diazepam
lovastatin
glyburide
hydrochlorothiazide and losartan
tiotropium bromide
bupropion
cyclobenzoprine
olmesartan medoxomil
eszopiclone
fexofenadine
omeprazole
tolterodine
fluconazole
naproxen
olmesartan medoximil and hydrochlorothiazide
irbesartan
mematine
Zyrtec
See Attached List
NKDA
Codeine
Iodine
epinepherine
atorvastatin
hydrocodone and acetaminophen
acetaminophen
hydrocodone
amoxicillin
levothyroxine
escitalopram
montelukast
esomeprazole
simvastatin
clopidogrel
metoprolol succinate
azithromycin
cetirizine
ezetimibe and simvastatin
lisinopril
oxycodone and acetaminophen
warfarin
hydrochlorothiazide
furosemide
cephalexin
fluticasone/salmeterol
pantoprazole
amlodipine
lansoprazole
metoprolol tartrate
venlafaxine
alendronate
valsartan
sertraline
ezetimibe
rosuvastatin
metformin
quetiapine
levofloxacin
valsartan and hydrochlorothiazide
atenolol
pioglitazone
duloxetine
prednisone
tamsulosin
albuterol
celecoxib
insulin glargine
risendronate
alprazolam
mometasone
sildenafil
fenofibrate
ramopril
propoxyphene napsylate and acetaminophen
ethinyl estradiol and drospirenone
trazodone
risperidone
acetaminophen and codeine
estrogens, conjugated/equine
losartan
donepezil
clonazepam
paroxetine
carvedilol
zolpidem
amoxicillin and clavulanate
dextroamphetamine and amphetamine
amlodipine and benazepril
digoxin
fluticasone propionate
gabapentin
sulfamethoxazole and trimethoprim
valacyclovir
triamterene and hydrochlorothiazide
pregabalin
ibuprofen
rosiglitazone
topiramate
lamotrigine
methylphenidate
lorazepam
latanoprost
ethinyl estradiol and norgestimate
fluoxetine
potassium chloride
rabeprazole
varenicline
clonidine
diazepam
lovastatin
glyburide
hydrochlorothiazide and losartan
tiotropium bromide
bupropion
cyclobenzoprine
olmesartan medoxomil
eszopiclone
fexofenadine
omeprazole
tolterodine
fluconazole
naproxen
olmesartan medoximil and hydrochlorothiazide
irbesartan
mematine
Zyrtec
penicillin
amoxicillin
cephalexin
keflex
erythromycin
E-Mycin
clarithromycin
Biaxin
azithromycin
Zithromax
ciprofolxacin
Cipro
levofloxacin
Levaquin
ofloxacin
Floxin
co-trimoxazole
Bactrim
trimethoprim
Proloprim
tetracycline
Sumycin
Panmycin
doxycycline
Vibramycin
gentamicin
Garamycin
tobramycin
Tobrex
See attached sheet for additional medications and/or drug allergies
PHYSICAL EXAMINATION
Mental Status:
Normal
Other:
Heart:
RRR w/o M
Other:
Lungs:
Clear
Other:
Other:
EYELID EXAM
OD
OS
Assessment:
Ptosis
Dermatochalasis
Ectropion
Entropion
Brow Ptosis
RUL
LUL
RLL
LLL
Other:
Plan:
Ptosis Repair
Blepharoplasty
Lateral Tarsal Strip
Entropion Repair
RUL
LUL
RLL
LLL
Other:
PAR conference held with the patient
Signature
Date:
Time:
REASSESSMENT:
H&P current and valid. No changes
Other:
Signature
Date:
Time:
PATIENT LABEL
ADDITIONAL MEDICATIONS AND/OR DRUG ALLERGIES - - CONTINUED
Patient Name:
DOB:
Reaction
REGULAR MEDICATIONS
DOSE
SCHEDULE
DRUG ALLERGIES
NAUSEA
VOMIT
RASH
SHOCK
OTHER
HISTORY / PHYSICAL - ADDITIONAL COMMENTS
PATIENT LABEL
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