Please complete this form on the afternoon of your surgery. Complete it to the best of your ability in order to expedite your visit and to minimize your time spent in the office. Be as complete as possible and submit this by 4:00pm on the afternoon of your surgery.
Your Surgeon's Name * Dr. Andrew Salem (University of Houston Surgery Center) Dr. Charles Thompson (Lake Charles Eye Clinic) Dr. William Hart (Lake Charles Hart Eye Center) Dr. Donald Falgoust (Lake Charles Falgoust Eye Med & Surgical) Dr. Steven Slade (Houston Slade & Baker Vision Center) Dr. Mark Crawford (Lake Charles Eye Clinic) Other Other Surgeon Not Listed *
You indicated "Other" for your cataract surgeon. Please list his / her name here.
Type of Lens Implant (if known) *
You will have had an intraocular lens implant (IOL) following the removal of your cataract. If you know the type of IOL you and your surgeon chose for this eye, please indicate it here.
I am not sure which IOL I have / will have accommodating (Crystalens, Trulign to focus near & far) accommodating toric (Crystalens Toric, Trulign Toric - both also correct astigmatism) extended depth of focus (Symfony to focus near & far) extended depth of focus toric (Symfony Toric + also corrects astigmatism) monofocal distance (focuses ONLY for distance) monofocal near (focuses ONLY for near) monovision (one IOL for distance, the fellow eye's IOL for near) multifocal (ReStor, Tecnis, PanOptix, others to focus near & far) multifocal toric (ReStor, Tecnis, PanOptix, others + all correct astigmatism) toric (corrects astigmatism) other Date of Your Surgery * Symptoms following surgery *
Do you have any of the following symptoms after your surgery? Choose all that may apply.
NONE of these symptoms blurred vision discharge flashes floaters foreign body sensation irritation metamorphopsia (things look wavy, tilted, or out of perspective) negative dysphotopsia (arc-shaped shadow, usually in the outside peripheral field of vision) pain photophobia (light / glare sensitivity) positive dysphotopsia (unwanted light, such as a streak, starburst, flicker) redness shadow, central shadow, peripheral shadows other Other Symptoms *
You indicated "Other" symptom(s) you were having, not listed above. Please describe those symptoms here.
Quality of Vision following surgery
What best describes the quality of your vision in the affected eye since your surgery? (Check all that apply)
colors appear more vivid objects appear brighter I feel as though I can drive without glasses I feel as though I can read without glasses I feel as though I can use computer without glasses I feel as though I can watch TV without glasses I am dissatisfied with results I am happy with outcome I am satisfied with results I note little or no change in vision other Other Quality of Vision Changes *
You indicated "Other" regarding the quality of your vision following surgery. Please describe here.
Eye Drop Medications
It is very important that you bring with you, to each of your follow up appointments, the following:
--all of the medication drops (in their bottles) you were prescribed for use following your cataract surgery.
--all of the printed materials you were issued at the time of your surgery, INCLUDING the post operative sheet with instructions on using your drops.
--the eyeglasses you were using before your cataract surgery
Upload Medication Instruction Sheet
If you are able to upload a copy of your post operative sheet with instructions on using your drops, please do so here. Do both sides if applicable. Remember, whether you are able to upload your drop sheet or not, bring it with you to each of your follow up appointments.
Drop files here or
Max. file size: 31 MB. Please check all that apply continued blood thinners resumed exercise resumed preop medications slept with eye shield taken eye medications as prescribed worn eye make-up Please check all that apply no discharge no discomfort no pain no pain, no discharge, no redness no redness Name
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