Implantable Lens Follow-Up Assessment Form
Implantable Lens Follow-Up Assessment Form for post-procedure evaluation of recovery, visual outcomes, symptoms, and next steps.
Date of Assessment
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Patient Initials
*
Please rate your overall visual clarity since the procedure.
*
Very Poor
1
2
3
4
Excellent
5
1 is Very Poor, 5 is Excellent
Select any symptoms you have experienced since your procedure.
*
Glare or halos
Blurry vision
Eye discomfort
Dryness
No symptoms
Other
Recovery Progress Assessment
*
Rows
Not at all
Somewhat
Mostly
Completely
Comfort with vision
1
2
3
4
Ability to perform daily tasks
5
6
7
8
Adherence to post-op instructions
9
10
11
12
Have you noticed any complications since the procedure?
*
No complications
Mild complications
Severe complications
How satisfied are you with the results of your procedure?
*
1
2
3
4
5
Would you like to discuss any concerns at your next visit?
*
Yes
No
Please describe any new or ongoing concerns.
Provider Notes (For Office Use Only)
Submit Assessment
Should be Empty: