SALEM LASER AND SURGERY CENTER

Patient Name:
Date of Surgery:

Surgeon:
Primary Physician:

PRE-OPERATIVE HISTORY & PHYSICAL
DIAGNOSIS:   Dermatochalasis       RUL     LUL     BUL
HPI:
Patient compains of reduced peripheral vision in right - left - both eye(s), headaches, brow ache, head tilt; and activities of daily living are adversely affected, particularly in the areas of: reading- driving- housework- knitting- sewing- crocheting     other:  
This surgery:

CHRONIC ILLNESSES (See Diagnoses)
Reaction
REGULAR MEDICATIONS
         DOSE
    SCHEDULE
       DRUG ALLERGIES
NAUSEA
VOMIT
RASH
SHOCK
OTHER
PHYSICAL EXAMINATION

Mental Status: Normal Other:

Heart: RRR w/o M Other:

Lungs: Clear Other:

Other:



Plan:   Schedule for surgery
EYELID EXAM OD

Lids:       dermatochalasis

Other:

Visual Field:  
OS

Lids:       dermatochalasis

Other:

Visual Field:  

Signature
Date:
Time:

REASSESSMENT:

Signature
Date:
Time:

PATIENT LABEL