Cataract Surgery Assessment & Referral Form

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Cataract Surgery Assessment & Referral Form
Patient referred for:
M Cataract Assessment
M Primary Cataract
M Secondary Cataract/YAG laser Tx
M 2nd Opinion on Previous Cataract Sx
Referral Date (m/d/y): _________________________________________
Patient Name (Dr./Mr./Mrs./Ms./Miss): __________________________ Sex:
M Female
M Male
DOB (m/d/y): ________________________________________________Alberta Health Care #: _______________________
Address: _____________________________________________________E-mail: ___________________________________
Telephone (res): ______________________________ (bus): ______________________ (cell): _________________________
City: ______________________________________ Prov/State: __________________ Postal/Zip: _____________________
If the Patient may not be reached or would have difficult answering questions, please indicate a contact person below:
Name of Contact Person: ________________________________Relationship to Patient:______________________________
Telephone (res): ______________________________ (bus): ______________________ (cell): __________________________
Assessing Doctor Name: ___________________________ Type of doctor:
M OD
M MD
M OPH
Address: ______________________________________________________PRACID #: ______________________________
Telephone: _______________________________________ Facsimile: _____________________________________________
City: ______________________________________ Prov/State: __________________ Postal/Zip: _____________________
Patient Health History
Ocular History (e.g., Injury, Amblyopia, Dry Eye, etc.): _________________________________________________________
______________________________________________________________________________________________________
If Patient has had previous eye surgery, please indicate type of sx:
OD ____________________________________
OS _____________________________________
Name of Surgeon: __________________________________________Location: _____________________________________
Date of Sx (m/d/y): _________________________________________Was a lens implanted?
M Yes
M No
Please Check:
Diabetes
Mobility Problem
Benign Prostatic Hypertrophy
Heart
M
M
M
M
Asthma
Auto Immune Disease
Immune Deficiency
Language Difficulty
M
M
M
M
Hepatitis
Ocular Herpes Zoster
Ocular Herpes Simplex
Hearing Difficulty
M
M
M
M
Atopy
Pregnancy/Nursing
Collagen Vascular Disease
Hypertension
M
M
M
M
Other health problems or concerns (If yes, please specify):
M
______________________________________________________________________________________________
List medications, include Imitrex®
, Accutane®
Amiodarone®
&/or Flomax®
:
(migraine)
(acne),
(cardiac anti-arrhythmic)
(urinary flow)
Ocular:___________________________________________ Systemic: ____________________________________________
___________________________________________
____________________________________________
___________________________________________
____________________________________________
List allergies to food (include nuts and shellfish) medications, surgical tape, eye drops, iodine &/or latex:
______________________________________________________________________________________________________
__________________________________________________ Specify if allergies are:
M Airborne
M Contact
PLEASE COMPLETE BOTH SIDES OF THIS FORM
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Printed in Canada
2013
36

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