Fill and Sign the Photosynthesis Limiting Factors Worksheet Form

3-12 MONTH POST-OPERATIVE FOLLOW-UP REPORT Alabama Eye Bank is Required by the Eye Bank Association of American to obtain the following information PLEASE PROVIDE ANY MISSING INFORMATION (FAX TO: 205-942-2129) Recipient Information Name Date of Birth Age Unique ID Number (SSN, Driver's License, Hospital ID, Medical Record) Ocular Diagnosis Ocular Diagnosis: Operative Eye Ocular Diagnosis: Non-operative Eye ‫ ܆‬Keratoconus ‫ ܆‬Keratoconus ‫ ܆‬Glaucoma ‫ ܆‬Glaucoma ‫܆‬Other: ________________________________________ ‫܆‬Other: ________________________________________ Surgical Information Tissue ID Number P.O. Number Surgeon Name Surgical Facility Date of Surgery Address Type of Surgery City State Zip ‫ ܆‬ALK ‫܆‬DALK ‫ ܆‬Tectonic ‫ ܆‬Trabeculectomy/shunt patch ‫܆‬OTHER:_______________________________ Alabama Eye Bank is Required by the Eye Bank Association of American to request the following information in regards to adverse reactions Yes No Yes No Did the patient experience a Primary Graft Failure associated with the surgery indicated above: If yes, what was the date of the diagnosis for the primary graft failure:____________________________ Was any post-operative infection observed: If yes, Please describe the infection:_________________________________________________________ If yes, how many days after the surgery was the infection identified:_______________________________ If yes, If yes, If yes, If yes, was the donor tissue the suspected source: ‫ ܆‬Yes ‫ ܆‬No was donor culturing performed: ‫ ܆‬Yes ‫ ܆‬No what was the cultures performed on: ‫ ܆‬Media only ‫ ܆‬Corneo-scleral rim ‫ ܆‬Both was the culture positive: ‫ ܆‬Yes ‫ ܆‬No If yes, organism(s) indentified:____________________________________________________________ Yes No Did the recipient develop any systemic infectious disease following the transplant: If yes, was the donor tissue the suspected source: ‫ ܆‬Yes ‫ ܆‬No If yes, what disease did the recipient develop:________________________________________________ Any additional post-operative findings or comments:___________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ Form# M1.550.1.1 Effective Date: 07/15/2010