| PATIENT:_________________________________________________ | |||
| SOCIAL SECURITY #:_______________________________________ | |||
| DATE OF BIRTH:____________________________________________________ | |||
TO THE DOCTOR: Please complete the following report, attaching copies of lab results for each condition. Please use the back of the form if additional space is needed. |
| 1. | Does this patient suffer from any impairment or disease? Yes _____ No ______ If yes: | |||||||||||||||||||||||||||||
| A. | What is the current diagnosis? | |||||||||||||||||||||||||||||
| B. | On what date was the diagnosis first made? ________________ | |||||||||||||||||||||||||||||
| C. | What is the date of onset, if different? ________________ | |||||||||||||||||||||||||||||
| D. | How long have you been treating the condition? ________________ | |||||||||||||||||||||||||||||
| E. | What is the most recent date of examination? ________________ Patient's height? _______________ Weight? _______________ | |||||||||||||||||||||||||||||
2. | Central visual acuity (Snellen):
| |||||||||||||||||||||||||||||
3. | Was the perpheral vision test results measured using the Goldman Perimeter? Yes _____ No _____ | |||||||||||||||||||||||||||||
4. | Does patient's eye impairment involve (a) monocular aphakia, or (b) Binocular aphakia? | |||||||||||||||||||||||||||||
5. | Field of vision: Contraction of visual field (Phakic eye: White target, 3mm white disc at distance of 330mm under illumination of not less than 7 foot candles; Aphakic eye: 6mm white disc at distance of 330mm without corrective lenses):
| |||||||||||||||||||||||||||||
6. | Muscle Function | |||||||||||||||||||||||||||||
| a. Is there any paralysis of the eye muscle? Yes _____ No _____ | ||||||||||||||||||||||||||||||
| b. If yes, please describe: | ||||||||||||||||||||||||||||||
| c. Is paralysis bilateral? Yes _____ No _____ | ||||||||||||||||||||||||||||||
7. | Does patient have hypertensive retinopathy? Please describe: | |||||||||||||||||||||||||||||
8. | Does patient have diabetic retinopathy? Please describe: | |||||||||||||||||||||||||||||
9. | Does patient have cataracts? Yes _____ No ______ Please describe: | |||||||||||||||||||||||||||||
10. | Does patient suffer from glaucoma? Yes _____ No _____ | |||||||||||||||||||||||||||||
11. | Has surgery been performed? Yes _____ No _____ | |||||||||||||||||||||||||||||
12. | What surgery? ________________________________________ Date: _________________________ Results: _____________________________________________ | |||||||||||||||||||||||||||||
13. | How does patient's present visual impairment impact on ability to work eight hours a day> | |||||||||||||||||||||||||||||
14. | Will lifting, stretching, pushing, pulling, stooping or prolonged reading aggravate eye condition? | |||||||||||||||||||||||||||||
15. | Please specify any limitations on ability to perform fine work: | |||||||||||||||||||||||||||||
16. | Please specify any limitation on ability to read: | |||||||||||||||||||||||||||||
17. | Please list all medications prescribed: | |||||||||||||||||||||||||||||
18. | Any side effects observed or reported? Yes _____ No ______ If yes, please specify: | |||||||||||||||||||||||||||||
| NOTE: ATTACH NOTATED FIELD CHARTS, INCLUDING DESCRIPTION OF TYPES AND SIZES OF TARGET AND TEST DISTANCE. | ||||||||||||||||||||||||||||||
| Signature: | ______________________________ |
| Name: (Print) | ______________________________ |
| Address: | ______________________________ ______________________________ |
| Telephone: | ______________________________ |