SA393 - Medical report for a person who is blind Completed Form Examples and Samples
View a practical example of a filled SA393 - Medical report for a person who is blind. See how to accurately complete this form with our detailed sample and guide.
Example of a Filled SA393 - Medical Report for a Person Who Is Blind
How this form was filled:
This example demonstrates how our AI intelligently extracts patient demographic data, diagnostic history, and clinical ophthalmological findings from a physician's informal consultation note to automatically populate the SA393 Medical Report for a Person Who Is Blind. The AI successfully identifies complex visual acuity metrics and contact details within unstructured text.
Source document used: Ophthalmology Consultation Notes
Dr. Sarah Jenkins - Ophthalmology Consultation Notes Patient: Eleanor Marie Vance, DOB 14/05/1958. CRN: 123-456-789-0. Current address: 42 Oakwood Avenue, Springfield, 62704. Contact: 555-0199. Patient presented today for review regarding progressive vision loss. Primary diagnosis is Age-Related Macular Degeneration (AMD), noted since 12/03/2021. Secondarily, she has early-stage Diabetic Retinopathy (diagnosed 05/01/2023) and Pseudophakia (post-surgery 10/11/2022). She also reports Glaucoma (15/07/2020), Cataracts (18/02/2019), and Dry Eye Syndrome (01/01/2018). Prognosis is poor, with no expected improvement in the next two years. Visual Acuity testing results: Right eye 6/120, Left eye 6/180. These results are corrected. The patient exhibits significant field of vision constriction to 8 degrees around central fixation in the better eye. I have completed this report as her primary Ophthalmologist. Her case is supported by records from Dr. Marcus Thorne at City Vision Center, 88 Medical Plaza, 62701, who referred her in 2024. Regarding documentation, I confirm there is no information in this report that is prejudicial to the patient’s health if disclosed. I am an Ophthalmologist (FRANZCO). Signed, Dr. Sarah Jenkins, 422 Ophthalmology Way, Springfield, 62704. Phone: 555-8888. Dated: 22/02/2026.
Information used to fill out the document:
- Patient Name: Eleanor Marie Vance
- Customer Reference Number: 123-456-789-0
- Primary Diagnosis: Age-Related Macular Degeneration (12/03/2021)
- Visual Acuity: R: 6/120, L: 6/180
- Field Constriction: 8 degrees in better eye
- Physician Details: Dr. Sarah Jenkins, Ophthalmologist
- Contact Details: 555-0199 (Patient), 555-8888 (Doctor)
What this filled form sample shows:
- Automatic extraction of fragmented dates and diagnosis pairs
- Smart mapping of visual acuity Snellen scale values
- Handling of nested address fields for both patient and referring ophthalmologist
- Boolean logic inference based on clinical findings (e.g., 'Yes' for visual impairment criteria)
- Contextual normalization of phone numbers and patient identifiers
Form specifications and details:
| Form Name: | SA393 - Medical Report for a person who is blind |
| Target Audience: | Medical Practitioners and Ophthalmologists |
| Key Functionality: | Documentation of severe visual impairment for government welfare eligibility |
| Difficulty: | High - Requires precise clinical terminology mapping |
| Categories: | Medi-Cal forms, medical forms, medical report forms, VA medical forms |
| Created: | May 19, 2026 06:59 PM |