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
