Retinal Detachment Recovery Tracking Form
Retinal Detachment Recovery Tracking Form for monitoring progress after retinal detachment treatment.
Patient Full Name
*
First Name
Last Name
Date of Review
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Reviewer Name (Clinician or Self)
*
Overall Recovery Status
*
Excellent
Good
Fair
Poor
Symptoms Experienced
*
Blurred vision
Floaters
Flashes of light
Eye pain
Redness
No symptoms
Other
Medication Adherence
*
All medications taken as prescribed
Missed 1-2 doses
Missed more than 2 doses
Stopped medications
Follow-Up Appointment Attendance
*
All attended
Missed one
Missed more than one
No appointments scheduled
Activity Restrictions Followed
*
All restrictions followed
Some restrictions not followed
Most restrictions not followed
No restrictions given
Vision Improvement Noticed
*
Significant improvement
Some improvement
No change
Worsening
Additional Notes or Comments
Submit Recovery Tracking
Should be Empty: