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Find us
Find us
Find a doctor
Locations
LVPEI Connect
LVPEI @Home
Eye conditions
Patient information
Patient information
Sub specialties
Surgeries & inpatients
Elderly patients
Insurance information
International patients
Services
Services
Research
Education
Vision rehabilitation
Community eye care
Eye innovation
Eye banking
Capacity building
Support us
News
About us
About us
Who we are
Our vision & mission
Our team
Patient stories
Careers
Shop
Pre-surgery Form
Name
(Required)
Dr.
Miss
Mr.
Mrs.
Ms.
Mx.
Prof.
Rev.
Prefix
First
Middle
Last
Age (only number, in Years)
(Required)
Birth date
MM slash DD slash YYYY
Gender
Male
Female
Other
Address
(Required)
Phone
(Required)
Email
Section Break
Do you smoke tobacco in any form?
(Required)
Yes
No
Do you have diabetes?
(Required)
Yes
No
Do you have high or low blood pressure?
(Required)
Yes
No
Do you have heart-related issues?
(Required)
Yes
No
Are you on blood thinners?
(Required)
Yes
No
What is your effort tolerance?
(Required)
Can climb 2 or more flights of stairs without getting breathless
Can climb 1 flight of stairs without getting breathless
Can walk 2km without getting breathless
Can do routine housework without getting breathless
Can only do my daily chores
I get breathless even while eating, talking. walking a few steps
Do you have Lung disease?
(Required)
Yes
No
Do you have any kidney problems?
(Required)
Yes
No
Do you have chronic liver disease?
(Required)
Yes
No
Do you have epilepsy?
(Required)
Yes
No
Did you ever have a brain stroke?
(Required)
Yes
No
Do you have any infection now?
(Required)
Yes
No
Did you ever have cancer?
(Required)
Yes
No
Do you have Anaemia?
(Required)
Yes
No
Do you have any congenital bleeding disorder?
(Required)
Yes
No
Are you on any of these drugs?
(Required)
Steroids
Immunosuppresents
No
Were you ever allergic to any drugs?
(Required)
Yes
No
Please list the drugs here
Did you ever have surgery under local or general anaesthesia?
(Required)
Yes
No
