Yag Peripheral Iridotomy Post-op Reporting Form

Patient & Consulting Doctor Information:

Patient Name: * Date of Birth: * Date of Yag PI: * Eye: * Surgeon: * Consulting Doctor: * Office location (if multiple):

Post-op Information:

Post-op * Day/Week # * Post-op Date: * Best Corrected Distance VA: 20/ * IOP (mmHg): * Time: * IOP Method: * Slit Lamp Exam: * Describe "other" findings: Gonioscopy (post PI): Patient Comments: Other findings:

Eye Medications

Patient eye medications and dosing schedule:

Assessment

Assessment(s):

Plan

Plan(s): Return to Clinic:

By entering my initials below and submitting this form, I am verifying that the information in this post-op report is accurate and true as of the date of the exam.

Doctor's Initials: *