Patient Data for Intraocular Lens Power Calculations Please Complete Information for Both Eyes

Patient Data for Intraocular Lens Power Calculations – please complete information for both eyes

Warren E. Hill, MD, FACS East Valley Ophthalmology, Ltd. 7525 E. Broadway Rd., Suite 6, Mesa, AZ 85208

Tel: +1 (480) 981-6130 FAX: +1 (480) 985-2426 Web site: www.doctor-hill.com E-mail:

Referring Ophthalmologist __________________________ Tel: __________________ FAX: __________________

Mailing Address ________________________________________________________________________________

Patient Data - please use reverse for any additional information Today’s date _________________________

Last Name __________________________________ First Name ____________________________ MI _______

Date of Birth _______________ Office ID Number, or SSN ________________________  Male  Female

Operative eye?  Right  Left Dominant eye?  Right  Left Date of surgery __________________

OD: K 1 ___________ x ________ K 2 ___________ x ________ Axial Length _________ mm (see note 1 beow)

Phakic patients ACD _______ mm Lens thickness _______ mm  Contact  Immersion  IOLMaster

Oldest refraction: _______ sph _______ cyl x ______ Current refraction: _______ sph _______ cyl x ______

Prior cataract surgery? Aphakic  Pseudophakic  PMMA  Silicone  Acrylic  Collamer

For pseudophakic axial length measurements, please do the A-scan in the aphakic mode (velocity = 1,532 m/sec)

Pseudophakic eyes: IOL manufacturer __________________ Model ____________ Power ___________

Best corrected Va ____________ Uncorrected Va ______________ Horizontal white-to-white _________ mm

Pre-operative pathology _______________________________________________________________________

Primary lens Manufacturer ___________________________________ Model ____________________

Secondary lens Manufacturer ___________________________________ Model ____________________

Planned Procedure  Primary  2°  R/RLens placement  Bag  Sulcus  Scleral fixation  A/C

 Scleral buckle?  Silicone oil?  Previous RK, PRK, LASIK? (see note 2 below)  Keratoconus?

Target post-operative refraction for the right eye  Plano  -0.25  -0.50  -0.75  Other _____________

OS: K 1 ___________ x ________ K 2 ___________ x ________ Axial Length _________ mm (see note 1 beow)