Ophthalmic Surgery Pre-Op Assessment Tool
Patient Information
Name
Date of Birth
Patient ID
Assessment Date
Surgical Details
Surgery Type
Surgeon
Planned Eye
Right
Left
Both
Scheduled Surgery Date
Medical History
Systemic Medical History
Ocular History
Drug Allergies
Current Medications
Examination
Visual Acuity
Intraocular Pressure
Other Ocular Findings
Anaesthetic Considerations
Type of Anaesthesia
Local
General
Topical
Anaesthetic Risk Assessment
ASA Grade
I
II
III
IV
V
Additional Notes