Patient:
Date of Birth:
DR. EAST
Sx Date:
DR. LAPOUR
Co-Manage
Yes
No
Drops
OD
Date
OS
Date
Cipro
EOM
PUPILS
Durezol
MR
20/15
20/20
20/25
20/30
20/40
20/50
20/60
20/70
20/80
20/100
20/200
20/400
20/800
CF @ 1'
CF @ 2'
CF @ 3'
CF @ 4'
CF @ 5'
CF @ 6'
20/15
20/20
20/25
20/30
20/40
20/50
20/60
20/70
20/80
20/100
20/200
20/400
20/800
CF @ 1'
CF @ 2'
CF @ 3'
CF @ 4'
CF @ 5'
CF @ 6'
Pred
BAT
20/15
20/20
20/25
20/30
20/40
20/50
20/60
20/70
20/80
20/100
20/200
20/400
20/800
CF @ 1'
CF @ 2'
CF @ 3'
CF @ 4'
CF @ 5'
CF @ 6'
20/15
20/20
20/25
20/30
20/40
20/50
20/60
20/70
20/80
20/100
20/200
20/400
20/800
CF @ 1'
CF @ 2'
CF @ 3'
CF @ 4'
CF @ 5'
CF @ 6'
NV
Ilevro
PRESSURE
Prolensa
dcard
SLE
Nevanac
DILATE
EXAM AT PRE-OP
NO
DILATED
SLIT LAMP
MAC OCT
REFRACT FIRST EYE:
GLUCOSE
TEAR LAB
RPS:
+
-
BP
P
R
PHYSICAL EXAMINATION
Mental Status:
Normal
Other
Heart:
RRR w/o M
Other
Lungs:
Clear
Other
Other:
See attached sheet for additional comments
Plan:
Schedule for surgery
Additional Info.
Change to orders
PRINT FORM