Post-Op Form "*" indicates required fields Patient DetailsTitleMrMrsMissMsDrProfName* First Last Tel homeMobileEmail Address Street Address Address Line 2 City Postcode D.O.B DD slash MM slash YYYY Date of Surgery: R DD slash MM slash YYYY Date of Surgery: L DD slash MM slash YYYY Additional InformationAdditional InformationRefraction and Vision :Right EyeUnaided Dist Vision Unaided Near Vision&WD Sphere Cylinder Axis Add BCVA BCVA (N) PH Left EyeUnaided Dist Vision Unaided Near Vision&WD Sphere Cylinder Axis Add BCVA PH BCVA (N) BEUnaided Dist Vision Unaided Near Vision&WD Sphere Cylinder Axis Add BCVA PH BCVA (N) EXAMINATION FINDINGSRightLeftTBUT (s)TBUT (s) - Right TBUT (s) - Left CorneaCornea - Right- Please Select -NormalAbnormalCornea - Left- Please Select -NormalAbnormalACAC - Right- Please Select -NormalAbnormalAC - Left- Please Select -NormalAbnormalLensLens - Right- Please Select -NormalAbnormal*Lens - Left- Please Select -NormalAbnormal*VitreousVitreous - Right- Please Select -NormalAbnormalVitreous - Left- Please Select -NormalAbnormalMaculaMacula - Right- Please Select -NormalAbnormal**Macula - Left- Please Select -NormalAbnormal**P.RetinaP.Retina - Right- Please Select -NormalAbnormalP.Retina - Left- Please Select -NormalAbnormalIop (mmHg)AT NCTIop (mmHg)AT NCT - Right Iop (mmHg)AT NCT - Left *Check for PCO **Check for CMOCommentsPLEASE TICK IF FURTHER ASSESSMENT IS REQUIRED EmailThis field is for validation purposes and should be left unchanged.
