Unique IDHiddenF2F Response–AcceptedRejectedHiddenED Response–AcknowledgedHiddenDealt with?–YesNoHiddenPractitionerHiddenUser RoleDo not edit this field unless instructed. HiddenPractitioner ID HiddenUser ID HiddenPractitioner HiddenPractitioner Email Address HiddenPDF URL Choose your practice*Ashby De La ZouchOptivision Opticians LtdSpecsavers OpticiansBurton and WrightSpecsavers LoughboroughBlaby EyecareSyston EyecareUppingham Road EyecareRyatt Optometry LtdEdmonds & SlatterHallcroft OpticiansSpecsavers Opticians OadbySpecsavers Melton MowbrayYour Sight OpticiansHinckley SpecsaversSimmons OptometristsrahulkishorMARKET HARBOROUGHClarke & Roskrow Styling OpticiansIf your practice doesn’t appear on this list, click here to sign up.PatientPatient ID173781737617374173721737017368173661736417362173601735817356173541735217350173481734517344173421734017337173351733317331173281732717325173231732117319173171731517313173111730917307173051730317301172991729717295172931729117289172871728517283172811727917277172751727317271172691726717265172631726117259172571725517253172511724917247172451724317241172391723717235172331723117229172271722517223172211721917217172151721317211172091720717205172031720117198171971719517194171921719017188171851718417182171801717817176171741717117169171671716517163171611715917158171541715217150171471714517143171411713917137171341713317131171291712717125171231712117119171171711417112171101710717106171041710217100170981709617094170921709017088170851708417082170801707817076170741707217070170681706617064170621706017058170561705417052170501704817046170441704217040170381703617034170321703017028170261702417022170201701817016170141701217010170081700617004170021700016998169961699416992169901698816986169841698216980169781697616974169721697016968169661696416962169601695816956169541695216950169481694616944169421694016938169361693416932169301692816926169241692216919169171691516913169111690916907169051690316901168991689716895168931689116889168871688516883168811687916877168751687316871168691686716865168631686116858168561685416852168501684816846168441684216840168381683616834168321683016828168261682416822168201681816816168141681216810168081680616804168021680016798167961679416792167901678716785167831678116779167771677516771167691676716765167631676116758167561675416752167501674816746167441674216740167381673616734167321673016728167261672416722167201671816716167141671216710167081670616704167021670016698166971669516693166911668916687166851668316680166781667516673166711666916667166651666316661166591665716655166531665116649166471664516643166411663816637166351663316631166291662716625166231662116619166171661516613166111660916607166051660316601165981659616594165921659016588165861658416582165801657816574165701655316548165461654416541165351653316531165291652516523165211651816516165091650616504165021650016498164931649116489164871648516477164751647316471164691646716465164631646116459164571645516453164511644816446164451644316441164391643716435164331643116429164271642516423164211641916417164141641216405164011639516389163881638616379163771636716351163471634416342163341632716323163201631316311163071630416302162981629616284162821628016278162681626616263162601625816256162471624116239162341622716225162231621916216162131620316201161991619716195161931619116189161871618516183161811617916177161751617216165161571614716144161411613716124161211611716114160941608616080160731607116068160671606116057160551604616043160411603216030160221601616014160121600115991159891596715963159601593915937159351591415906159041590215900158981589515892158901588815886158841588315881158781587615870158681586615864158581585015836158321582815824158201581115805158031578415781157791577115768157541572115719156971568815685156841568215674156721567015667156651566015656156541565215650156481564615644156361561215610156081560415602156001559615594155601555615552155421554015535155331552715453154491544315441154391543515432154301542415422154171541415412154061540115393153911538615383153811536215358153531533515333153301532815325153231531915296152871528515275152681526715256152491524115236152251522115219152171521315199151881518615180151751515815150151351513315122151201511015106151031510115095150931508615081150731507115063150611505915057150471504215040150361503415032150241502215020150181498614983149771497514973149651496414960149581495214950149271478514779147771477514773147671474614739147371473414721147151470414695Name First Last Mobile PhoneHome PhoneDate of birth DD slash MM slash YYYY Address Street Address Address Line 2 City County / State / Region ZIP / Postal Code HiddenGP Reason for Referral–CataractYAG laser capsulotomySuspect glaucomaSending test resultsOtherOther reason for referral*Which eye–RELEBEHistoryPrevious Ocular HistoryGeneral HistoryDriver–YesNoRisk and Benefits of Cataract Surgery explained–YesNoRefractionRESph–-20.00-19.50-19.00-18.50-18.00-17.50-17.00-16.50-16.00-15.50-15.00-14.50-14.00-13.50-13.00-12.50-12.00-11.50-11.00-10.50-10.00-9.50-9.00-8.50-8.00-7.50-7.00-6.50-6.00-5.50-5.00-4.75-4.50-4.25-4.00-3.75-3.50-3.25-3.00-2.75-2.50-2.25-2.00-1.75-1.50-1.25-1.00-0.75-0.50-0.250.00+0.25+0.50+0.75+1.00+1.25+1.50+1.75+2.00+2.25+2.50+2.75+3.00+3.25+3.50+3.75+4.00+4.25+4.50+4.75+5.00+5.50+6.00+6.50+7.00+7.50+8.00+8.50+9.00+9.50+10.00+10.50+11.00+11.50+12.00+12.50+13.00+13.50+14.00+14.50+15.00+15.50+16.00+16.50+17.00+17.50+18.00+18.50+19.00+19.50+20.00Cyl–-6.00-5.75-5.50-5.25-5.00-4.75-4.50-4.25-4.00-3.75-3.50-3.25-3.00-2.75-2.50-2.25-2.00-1.75-1.50-1.25-1.00-0.75-0.50-0.250.00+0.25+0.50+0.75+1.00+1.25+1.50+1.75+2.00+2.25+2.50+2.75+3.00+3.25+3.50+3.75+4.00+4.25+4.50+4.75+5.00+5.25+5.50+5.75+6.00Axis–2.557.51012.51517.52022.52527.53032.53537.54042.54547.55052.55557.56062.56567.57072.57577.58082.58587.59092.59597.5100102.5105107.5110112.5115117.5120122.5125127.5130132.5135137.5140142.5145147.5150152.5155157.5160162.5165167.5170172.5175177.5180VA–Not possible1.21.110.90.80.70.60.50.40.30.20.10-0.1-0.2-0.3VA with pinhole–Not possible1.21.110.90.80.70.60.50.40.30.20.10-0.1-0.2-0.3LESph–-20.00-19.50-19.00-18.50-18.00-17.50-17.00-16.50-16.00-15.50-15.00-14.50-14.00-13.50-13.00-12.50-12.00-11.50-11.00-10.50-10.00-9.50-9.00-8.50-8.00-7.50-7.00-6.50-6.00-5.50-5.00-4.75-4.50-4.25-4.00-3.75-3.50-3.25-3.00-2.75-2.50-2.25-2.00-1.75-1.50-1.25-1.00-0.75-0.50-0.250.00+0.25+0.50+0.75+1.00+1.25+1.50+1.75+2.00+2.25+2.50+2.75+3.00+3.25+3.50+3.75+4.00+4.25+4.50+4.75+5.00+5.50+6.00+6.50+7.00+7.50+8.00+8.50+9.00+9.50+10.00+10.50+11.00+11.50+12.00+12.50+13.00+13.50+14.00+14.50+15.00+15.50+16.00+16.50+17.00+17.50+18.00+18.50+19.00+19.50+20.00Cyl–-6.00-5.75-5.50-5.25-5.00-4.75-4.50-4.25-4.00-3.75-3.50-3.25-3.00-2.75-2.50-2.25-2.00-1.75-1.50-1.25-1.00-0.75-0.50-0.250.00+0.25+0.50+0.75+1.00+1.25+1.50+1.75+2.00+2.25+2.50+2.75+3.00+3.25+3.50+3.75+4.00+4.25+4.50+4.75+5.00+5.25+5.50+5.75+6.00Axis–2.557.51012.51517.52022.52527.53032.53537.54042.54547.55052.55557.56062.56567.57072.57577.58082.58587.59092.59597.5100102.5105107.5110112.5115117.5120122.5125127.5130132.5135137.5140142.5145147.5150152.5155157.5160162.5165167.5170172.5175177.5180VA–Not possible1.21.110.90.80.70.60.50.40.30.20.10-0.1-0.2-0.3VA with pinhole–Not possible1.21.110.90.80.70.60.50.40.30.20.10-0.1-0.2-0.3K ReadingsValueAxisValueAxisValueAxisValueAxisOCTRE Drop files here or Select files Accepted file types: jpg, gif, png, pdf, mp4, wmv, Max. file size: 195 MB. LE Drop files here or Select files Accepted file types: jpg, gif, png, pdf, mp4, wmv, Max. file size: 195 MB. Corneal TopographyRE Drop files here or Select files Accepted file types: jpg, gif, png, pdf, mp4, wmv, Max. file size: 195 MB. LE Drop files here or Select files Accepted file types: jpg, gif, png, pdf, mp4, wmv, Max. file size: 195 MB. Visual FieldsRE Drop files here or Select files Accepted file types: jpg, gif, png, pdf, mp4, wmv, Max. file size: 195 MB. LE Drop files here or Select files Accepted file types: jpg, gif, png, pdf, mp4, wmv, Max. file size: 195 MB. IOPMethod–GATNCTICarePerkinsTonopenTime : Hours Minutes Right Eye (mmHg)Average reading–567891011121314151617181920212223242526272829303132333435363738394041424344454647484950>50Left Eye (mmHg)Average reading–567891011121314151617181920212223242526272829303132333435363738394041424344454647484950>50Ocular ExaminationOcular Motility–NormalAbnormalOcular Motility CommentsPupils–NormalAbnormalAbnormal Pupil CommentsAmsler ChartEnter right eye and left eye below.Right Eye–NormalAbnormalLeft Eye–NormalAbnormalAbnormal Amsler Chart Comments*Colour VisionEnter right eye and left eye below.Right Eye–NormalAbnormalLeft Eye–NormalAbnormalAbnormal Colour Vision Comments*ExternalRight Eye–NormalAbnormalLeft Eye–NormalAbnormalAbnormal External Comments*HiddenAnterior SegmentHiddenRight Eye–NormalAbnormalHiddenLeft Eye–NormalAbnormalHiddenAbnormal Anterior Segment Comments*HiddenGonioscopyHiddenRight Eye–NormalAbnormalHiddenLeft Eye–NormalAbnormalHiddenAbnormal Gonioscopy Comments*LensRight Eye–NormalAbnormalLeft Eye–NormalAbnormalAbnormal Lens Comments*HiddenVitreousHiddenRight Eye–NormalAbnormalHiddenLeft Eye–NormalAbnormalHiddenAbnormal Vitreous Comments*DiscsRight Eye–NormalAbnormalLeft Eye–NormalAbnormalAbnormal Discs Comments*PeripheryRight Eye–NormalAbnormalLeft Eye–NormalAbnormalAbnormal Periphery Comments*MaculaRight Eye–NormalAbnormalLeft Eye–NormalAbnormalAbnormal Macula Comments*HiddenLid HygieneHiddenLid Hygiene Measures Given–YesNoHiddenCoronavirusHiddenCOVID-19 Checker*Does the patient have any of the following symptoms: New, continuous cough High temperature Loss of taste and smell –NoYesHiddenVulnerable Group Checker*Is the patient in any of the following groups, check here: Check Symptoms –NoYesHiddenClinical ImpressionHiddenDate* DD slash MM slash YYYY Any other informationHiddenRed Flags Show red flags Hidden Sudden onset of red and painful eye which may be associated with photophobia or nausea Severe reduction or loss of vision Recent onset of shadows or ‘curtaining’ in the field of vision Sudden onset ptosis and diplopia Penetrating injury Chemical injury HiddenNo Red Flags No red flags Image TokenHiddenWorking Diagnosis* Show list HiddenType* Normal External Anterior Posterior Other Not listed Unknown at this point HiddenNot listed diagnosisHiddenExternal* Blepharitis – anterior Blepharitis – posteior Blepharitis – mixed Chalzia CLAPC Concretions Conjunctiva medicamentosa Conjunctival retention cyst Conjunctivitis – Allergic Conjunctivitis – Bacterial Conjunctivitis – Viral Dacroyostitis Dry eyes – aqueous deficient Dry eyes – evaporative Ectropion Entropion Episcleritis Foreign body Hordeloum Lacrimal drainage obsruction Meibomium Gland Dysfunction Mollescum contagiusm Ocular rocascea Sub tarsal foreign body Trichiasis Xanthalasma HiddenAnterior* Anterior chamber angle anomalies Corneal – REE Corneal – contact lens related Corneal – Endothellial dystrophies Corneal – Epithelial dystrophies Corneal abrasion Corneal anomalies Corneal foreign body Keratitis – herpetic / viral Keratitis – mild microbial Keratitis – severve Lens opacities Photokeratitis Pigment dispersion syndrome Pinguecula Pseudo exfoliation syndrome Pterygium Scleritis Sub conjunctival haemorrage Uveitis (anterior, acute and recurrent) Uveitis (anterior, acute and recurrent) HiddenPosterior* BRAO BRVO CRAO CRVO Diabetic Retinopathy, worsenning R2, M1 or R3 Retina – heamorrghes Retina – Choriodal neavi Retina – CHRPE Retina – Dry ARMD Retina – Epi retinal membrane Retina – Periperheral degneration Retina – Retinoschsis Retina – Wet ARMD Scleritis HiddenOther* Adult squints Anomalous discs Contact lens problems Elevated IOPs Epiphoria Epiphoria Facial palsy Glaucomatous discs Herpes simplex Lid twitch Not specified Ocular migraine Ocular motitlty anomalies Pupil anomaly Pupil anomaly – physiological Refractive Suspect glaucomatous disc Visual field anomalies vitreoretinal Posterior vitreous detachment vitreoretinal Vitreous opacities HiddenTreatment*–Self careMedicines requiredNone requiredRefer to EDHiddenOTC Medicine Categories* Lid hygiene Lubricants Oral anti virals Oral antibiotics Oral antibiotics Oral ocular hypotensives Topical Anti histamines Topical anti virals Topical antibiotics Topical ocular hypotensives Topical steroids HiddenMedicine* Acetazolamide Acetylcysteine Aciclovir Acrivastine Amoxicillin Antazoline Sulfate Aspirin Atropine Sulfate Azelastine Hydrochloride Azithromycin Dihydrate Carbomers Carmellose Sodium Cetirizine Hydrochloride Chloramphenicol Chlorphenamine Maleate Ciprofloxacin Cyclopentolate hydrochloride Dexamethasone Diclofenac Sodium Doxycycline Emedastine Epinastine Hydrochloride Erythromycin Eye Nutrients Fluorescein Sodium Fluorometholone Flurbiprofen Flurbiprofen Sodium Fusidic Acid Ganciclovir Gentamicin Sulfate Homatropine Hydrobromide Hydroxyethylcellulose Hypromellose Ibuprofen Ketorolac Trometamol Ketotifen Levocabastine Levofloxacin Lid Care Products Lidocaine Hydrochloride (Lignocaine) Liquid Paraffin Lodoxamide Loratadine Loteprednol Etabonate Macrogols (Polyethylene Glycols) Minocycline Moxifloxacin Nedocromil Sodium Ofloxacin Olopatadine Oxybuprocaine Hydrochloride (Benoxinate) Oxytetracycline Paracetamol Paraffin, Yellow, Soft Phenylephrine Hydrochloride Pilocarpine Polymyxin B Sulfate Polyvinyl Alcohol Prednisolone Propamidine Isetionate Proxymetacaine Hydrochloride Rimexolone Sodium Cromoglicate Sodium Hyaluronate Soya Lecithin Soybean Oil Tetracaine Hydrochloride (Amethocaine) Tetracycline Tropicamide Hydrochloride HiddenOTC Medicine* Chloramphenicol – drops Chloramphenicol – ointment Fusidic Acid Hypromellose Carbomer 980 Liquid paraffin and white soft paraffin Antazoline and Xylometazoline Sodium Cromoglycate Sodium Hyaluronate This patient must be seen in ED. Call 0116 258 6273.HiddenOutcome*–DischargeDischarge – advise sight testPost-Op RequiredAttend EDPlease make a courtesy call to ED about this patient on 0116 258 6273. An automatic referral will be made as well. Please direct patient to Windsor Eye Casualty.Confirm this has been actioned Yes HiddenSend confirmation message to patient–YesNoHiddenAdditional information to send to patientThis will be sent via SMSHiddenCUES Assigned User HiddenCUES Practice Email HiddenCUES Practice PhoneOutcome*Should the patient be seen in the LUECs service, or in practice?–Refer to LUECs ServiceRefer to community optometrist practice (CUES)The referral will be passed to UHL who will contact the patient to make a LUECS appointment.You have selected a red flag. An automatic referral will be made to ED. Please advise the patient.This patient must be seen in ED. Call 0116 XXX XXXX.Patient has coronavirus symptoms, direct them to 111.Additional Information*This will be sent to either the GP or ED.Patient Consent*I confirm that the patient has consented to this referral, and that, in order for the referral to be processed, this must be confirmed by the patient. I confirm that the patient has consented. Data Accuracy*I confirm that the information that forms this referral has been accurately obtained and completed to the best of my ability. I confirm that this referral has been accurately obtained and completed to the best of my ability. CommunicationSend advice and guidance leaflet to patient Yes Choose letter template to patient*This will only send if the patient has provided an email address.–Scratched corneaSight test patient leafletBlepharitis symptoms and treatmentCataracts symptoms and treatmentDry eye symptoms and treatmentFlashes and floaters symptoms and treatmentMGD symptoms and treatmentBacterial and viral conjunctivitisAmsler chartAMD leafletAllergic conjunctivitisHiddenCall Recording URL HiddenCall lengthHiddenImageAccepted file types: jpg, png, gif, Max. file size: 10 MB.HiddenImage Path HiddenActionedNoYesUntitled