Cataract Pre Surgical Health Form - Full - Production

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Cataract Pre Surgical Health Form - Full - Production

Cataract Pre Surgical Health Form - Full - Production

This form is designed to help you have your cataract treated in the best way possible. You may wish to ask a family member to help you with this form, or complete it with a member of staff at your optometrists.

43Questions

HIPAA

Compliance

1
PESNumberThis should be automatically filled - if not check your link and copy and paste exactly.
2
Do you have problems with glare in sunlight, or from car headlights?
YESNO
3
Is your sight causing you difficulties with mobility? For example crossing roads, managing steps, using buses?
YESNO
4
Do you drive?
No
Yes, but don't feel confident driving any more
Yes, and I still feel confident
5
Is your vision affecting your ability to look after yourself? For example cooking, housework or dressing?
YESNO
6
Is your quality of life affected by visual difficulties, for example reading, watching television, hobbies or sports?
YESNO
7
Is your vision causing problems socially? For example recognising people, handling coins and notes?
YESNO
8
How much better do you think your life might be without a cataract?
A lot
Moderately
Slightly
Not at all
9
Do you currently have, or have you previously had, any other eye conditions?
YESNO
10
Please provide details of your previous or current eye conditionFor example, I have glaucoma in my left eye
11
Have you had any previous eye operations including refractive surgery or laser treatment?
YESNO
12
Please give details of the eye operations including refractive surgery or laser treatment? Describe any problems with the surgery if applicable.
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Large
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Small
Ok
Ok
13
Do you have high blood pressure requiring treatment?
YESNO
14
Is your high blood pressure currently stable?
YESNO
15
Are you taking medication for your high blood pressure?
YESNO
16
Do you have diabetes (high blood sugar?)
YESNO
17
Do you manage your diabetes by
Taking insulin injections
Taking tablets
Managing by diet alone
18
What is your most recent HbA1C reading - if you know it?
19
Do you have angina?
YESNO
20
Have you had a heart attack within the last three months?
YESNO
21
Do you have epilepsy or blackouts?
YESNO
22
Do you suffer from head or neck stiffness?
YESNO
23
Do you have recurrent breathing difficulties?For example severe asthma or chronic bronchitis?
YESNO
24
Can you walk a single flight of stairs without getting short of breath?
YESNO
25
Can you lie flat for up to 30 minutes?
Yes
No - because I get short of breath
No - because of joint or muscle stiffness
26
Do you suffer from panic attacks or claustrophobia?Claustrophobia is a fear of small spaces
YESNO
27
Do you smoke?
YESNO
28
How many a day?
Less than 5 per day
Less than 10 per day
Less than 20 per day
Less than 25 per day
More than 25 per day
29
Do you regularly take any of the following medicines?
Heart medicine (e.g. Digoxin)
High blood pressure medicine
Steroids
Aspirin
Anticoagulants or blood thinning medicines(e.g. Warfarin/Clopidrogel)
Tamsulosin (Flomax)
Inhalers
Insulin or blood sugar tablets
30
Are you allergic to local anaesthetic?
YESNO
31
Are you allergic to any medicine?
YESNO
32
Please provide details of the medicine or tablets you are allergic to, for example penicillin
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Large
Normal
Small
Ok
Ok
33
Please describe any other medicines or tablets you are taking currently
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Small
Ok
Ok
34
Are you able to walk unaided?
YESNO
35
Can you walk with the aid of a stick or helper?
YESNO
36
If required, would you be able to apply eye drops?
YESNO
37
Do you have family or friends who could help you apply eye drops?
YESNO
38
If you need a home visit for the assessment, are you able to travel to the treatment location?
YESNO
39
Do you have significant hearing loss?
YESNO
40
Do you require someone who can use sign language to be present?
YESNO
41
Do you require an interpreter?
YESNO
42
If so, which language do you require the interpreter to speak?
43
Here you can tell us any other information that you might think is useful
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Ok
Should be Empty:

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