Cataract Surgery Assessment & Referral Form Page 2
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2Cataract Surgery Assessment & Referral Form cont’d
Patient Name: __________________________________________________________________________________________
Does Patient have cataracts?
M Yes
M No
If Yes, indicate:
M OD
M OS
Does Patient have glaucoma?
M Yes
M No
If Yes, indicate:
M OD
M OS
Current or last IOP: ________________ OD ______ OS
IOP measured by:
M AT
M NCT
Does Patient have macular degeneration?
M Yes
M No
If Yes, indicate:
M OD
M OS
Any abnormalities of the cornea?
M Yes
M No
If Yes, indicate:
M OD
M OS
If Yes, please explain: _____________________________________________________________________________________
______________________________________________________________________________________________________
Any abnormalities of the iris?
M Yes
M No
If Yes, indicate:
M OD
M OS
If Yes, please explain: _____________________________________________________________________________________
______________________________________________________________________________________________________
Best Corrected Visual Acuity
OD 20/ _______________
OS 20/ ___________________________
Current Spectacles Rx
OD ___________________
OS ______________________________
Does the patient wear prism(s) in his/her current spectacles?
M Yes
M No
Would you prefer that our office (Calgary or Edmonton) performed follow-up care?
M Yes
M No
M Other
If Other, please specify: __________________________________________________________________________________
Does Patient wear contact lenses?
M Yes
M No
If Yes, indicate:
M Hard
M Soft
M Rigid Gas Permeable
M Other, please specify: _____________________
M Instructed to leave out contact lenses for ______ days prior to assessment
Comments: ____________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
Has Gimbel Eye Centre seen this Patient previously?
M Yes
M No
Signature of Assessing Doctor: __________________________________________
For Office Use Only
Patient ID: ____________________________________________________________________________________________
Appointment Date: ____________________________________Appointment Type: __________________________________
Comments: ____________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
M Gimbel Eye Centre Calgary Fax: (403) 202-3303
M Gimbel Eye Centre Edmonton Fax: (780) 452-4114
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Last Revised April 2013
37
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