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)

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 left eye  Plano  -0.25  -0.50  -0.75  Other _____________

1. If the axial length is greater than 26.0 mm, please call our office for instructions on how to measure the axial length.

2. For any prior keratorefractive surgery, we have a separate data sheet that must be completed for both eyes.