visus corretto in od - Carlo Masci OCULISTA
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DATA_________________________ COGNOME__________________________________NOME____________________________________ Indirizzo__________________________________________Telefono______________________________ Data di nascita _____________________________ PROFESSIONE________________________________ Valutazione psicologica____________________________________________________________________ Anamnesi (malattie del collagene, malattie vascolari incontrollate, malattie autoimmuni, immuno-depressione o terapia con immunodepressori, storia di formazioni di cheloidi, diabete instabile o incontrollato, gravidanza, allattamento, cheratocono, glaucoma, contraccettivi orali, alterazioni del ciclo mestruale primario, terapie ormonali) _______________________________________________________________________________________ _______________________________________________________________________________________ OD LENTE IN USO__________________________________Visus con lente in uso__________________ OS LENTE IN USO__________________________________Visus con lente in uso__________________ OD AUTOREFRATTOMETRIA____________________________________________________________ OS AUTOREFRATTOMETRIA____________________________________________________________ LA REFRAZIONE E’ INVARIATA DA CIRCA __________________________ USA LAC ___________________ORE DI PORTO GIORNALIERO__________DA ANNI___________ HA SOSPESO L’USO DELLE LAC DA CIRCA_____________________________________________ OFTALMOMETRIA OD: K1__________________K2_____________________asse________________ OFTALMOMETRIA OS: K1__________________K2_____________________asse________________ VISUS NATURALE OD_________________________ OS______________________________ VISUS CORRETTO IN OD_______________________________________________________________ VISUS CORRETTO IN OS_______________________________________________________________ REFRAZIONE IN CICLOPLEGIA OD_______________________________________________________ REFRAZIONE IN CICLOPLEGIA OS_______________________________________________________ ODta _______________mmHg OSta _______________mmHg ESAME ORTOTTICO___________________________________________________________________ _______________________________________________________________________________________ OD BUT__________________________OS BUT________________________ OD Schirmer I_____________________OS Schirmer I____________________ SEGMENTO ANTERIORE (Opacità cristallino - Posizione pupilla - Profondità camera anteriore) _______________________________________________________________________________________ CORNEA OD _______________________________________________________________________________________ _______________________________________________________________________________________ CORNEA OS _______________________________________________________________________________________ _______________________________________________________________________________________ PACHIMETRIA OD____________________ OS__________________________ MICROSCOPIA ENDOTELIALE OD____________________ PUPILLOMETRIA OD________________________ OS______________________ OS_________________________ TOPOGRAFIA CORNEALE_______________________________________________________________ BIOMETRIA OD __________________________________OS___________________________________ FO OD _______________________________________________________________________________________ _______________________________________________________________________________________ FO OS _______________________________________________________________________________________ _______________________________________________________________________________________ NOTE: _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ Firma del medico
