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Patient Information
Patient Information
Name:______________________________________________________________ Address:_____________________________________________________________ Sex:________________________
Medical History
If your patient has any of the following conditions or is
Exam Date:_________________ Dominant Eye: OD / OS taking the listing of medications, please circle.

Known Allergies:_____________________________________ Keratoconus, Collagen Vascular Disease, Autoimmune, Immunodeficiency Disease, Pregnant or Nursing, Taking Positive medical or surgery history:______________________ Pre-Operative Information - OD
Pre-Operative Information - OS
Corneal haze:_________________ IOP:_________________ Corneal haze:_________________ IOP:_________________ VA-sc:_______ VA-cc:________ Pupil: Photopic______Scotopic______ VA-sc:_______ VA-cc:________ Pupil: Photopic______Scotopic______
Previous ocular surgery:_____________________________________________ Previous ocular surgery:_____________________________________________
Slit lamp exam: Normal / Abnormal Dilated exam: Normal / Abnormal Slit lamp exam: Normal / Abnormal Dilated exam: Normal / Abnormal
Diagnosis: Myopia / Hyperopia / Ast / _________________________
Diagnosis: Myopia / Hyperopia / Ast / _________________________ Keratometry: K1________AXIS_______ K2________AXIS______
Keratometry: K1________AXIS______ K2_________AXIS_______
Correction
Correction
Desired:
Desired:
WaveScan
WaveScan
Refraction:
Refraction:
WaveScan
WaveScan
Physician adj:
Physician adj:
WaveScan Nomogram Adj.:___________
WaveScan Nomogram Adj.:___________
gram Adj:______________
Correction: (Circle One)
Correction: (Circle One)
PTK / PRK / PRKA / LASIK / HYP / HYPA / LASEK PTK / PRK / PRKA / LASIK / HYP / HYPA / LASEK CUSTOM / RETREAT RT W-RECUT / FLAP LIFT ONLY CUSTOM / RETREAT RT W-RECUT / FLAP LIFT ONLY Vertex Distance: 12.50 / ______mm Hertz: 8 10 ________
Vertex Distance: 12.50 / ______mm Hertz: 8 10 ________
Blend Zone: Y N Ablation Zone: 6 / 6.5 / Hyp / Custom
Blend Zone: Y N Ablation Zone: 6 / 6.5 / Hyp / Custom
Plate: 160 / 180 / 200 / _____ Ring: 8.5 / 9.5 / 8.5M / 9.5M Plate: 160 / 180 / 200 / _____ Ring: 8.5 / 9.5 / 8.5M / 9.5M
Intralase: Depth: ___________ Diameter: ________________
Intralase: Depth: ___________ Diameter: ________________
Pentacam / Topography to be done at Eye Bank? Yes No
Pentacam / Topography to be done at Eye Bank? Yes No
If not done at SDEB: Normal / Abnormal Pachometry: ___________
DEB : Normal / Abnormal Pachometry: ___________
WaveScan completed: Y / N / NA Date:_____________________ WaveScan completed: Y / N / NA Date:___________________ ALL AREAS MUST BE COMPLETED IF APPLICABLE PRIOR TO SURGERY
Physician’s Signature:________________________ Physician’s Phone:___________________ Fax:_________________
San Diego Eye Bank
Established: 4/96 Revised: 7/97, 1/98, 6/98, 6/99, 8/99, 9/99, 9/00, 7/01, 3/02, 5/02, 7/03, 9/04, 12/04, 2/05, 8/06, 10/09:NB, 3/12:ES Patient Information
Standard PRK, LASIK, LASEK or PTK All areas need to be completed except for WaveScan refraction, WaveScan physician adj and WaveScan completed: Y or N CustomVue All areas need to be completed, however when entering in the treatment, complete only WaveScan refraction or WaveScan physician adj. Do not use Correction Desired. Established: 4/96 Revised: 7/97, 1/98, 6/98, 6/99, 8/99, 9/99, 9/00, 7/01, 3/02, 5/02, 7/03, 9/04, 12/04, 2/05, 8/06, 10/09:NB, 3/12:ES

Source: http://www.sdeb.com/pdf/FExc-014PatientInformationWithCustom.pdf