SA393 - Medical report for a person who is blind Instructions

Please provide any additional relevant information in this field.

Enter the first line of the patient's street address.

Enter the suburb or town of the patient's address.

Enter the postcode of the patient's address.

Please provide the patient's contact phone number, including the area code.

Please enter the first segment of the customer's reference number.

Please enter the second segment of the customer's reference number.

Please enter the third segment of the customer's reference number.

Please enter the fourth and final segment of the customer's reference number.

Provide the patient's date of birth.

Enter the degree of constriction of the field of vision for the right eye in arc degrees around central fixation.

Enter the degree of constriction of the field of vision for the left eye in arc degrees around central fixation.

Enter the full name of the ophthalmologist. Fill only if 'Is the field of vision constricted to 10 degrees or less of arc around central fixation in the better eye irrespective of corrected visual acuity (equivalent to 1/100 white test object)?' is 'Yes'.

Enter the first line of the ophthalmologist's address. Fill only if 'Is the field of vision constricted to 10 degrees or less of arc around central fixation in the better eye irrespective of corrected visual acuity (equivalent to 1/100 white test object)?' is 'Yes'.

Enter the second line of the ophthalmologist's address. Fill only if 'Is the field of vision constricted to 10 degrees or less of arc around central fixation in the better eye irrespective of corrected visual acuity (equivalent to 1/100 white test object)?' is 'Yes'.

Enter the postcode of the ophthalmologist's address. Fill only if 'Is the field of vision constricted to 10 degrees or less of arc around central fixation in the better eye irrespective of corrected visual acuity (equivalent to 1/100 white test object)?' is 'Yes'.

Enter the contact phone number of the ophthalmologist, including the area code. Fill only if 'Is the field of vision constricted to 10 degrees or less of arc around central fixation in the better eye irrespective of corrected visual acuity (equivalent to 1/100 white test object)?' is 'Yes'.

Enter the year of the most recent referral. Fill only if 'Is the field of vision constricted to 10 degrees or less of arc around central fixation in the better eye irrespective of corrected visual acuity (equivalent to 1/100 white test object)?' is 'Yes'.

Please provide the full name of the ophthalmologist or optometrist completing this report. Fill only if 'Is the field of vision constricted to 10 degrees or less of arc around central fixation in the better eye irrespective of corrected visual acuity (equivalent to 1/100 white test object)?' is 'Yes'.

Please enter the qualifications of the ophthalmologist or optometrist completing this report. Fill only if 'Is the field of vision constricted to 10 degrees or less of arc around central fixation in the better eye irrespective of corrected visual acuity (equivalent to 1/100 white test object)?' is 'Yes'.

Please enter the first line of the address for the ophthalmologist or optometrist. Fill only if 'Is the field of vision constricted to 10 degrees or less of arc around central fixation in the better eye irrespective of corrected visual acuity (equivalent to 1/100 white test object)?' is 'Yes'.

Please enter the second line of the address for the ophthalmologist or optometrist, such as suburb, state, or region. Fill only if 'Is the field of vision constricted to 10 degrees or less of arc around central fixation in the better eye irrespective of corrected visual acuity (equivalent to 1/100 white test object)?' is 'Yes'.

Please enter the postcode for the address of the ophthalmologist or optometrist. Fill only if 'Is the field of vision constricted to 10 degrees or less of arc around central fixation in the better eye irrespective of corrected visual acuity (equivalent to 1/100 white test object)?' is 'Yes'.

Please enter the contact phone number, including the area code, for the ophthalmologist or optometrist. Fill only if 'Is the field of vision constricted to 10 degrees or less of arc around central fixation in the better eye irrespective of corrected visual acuity (equivalent to 1/100 white test object)?' is 'Yes'.

Please provide the signature of the ophthalmologist or optometrist. Fill only if 'Is the field of vision constricted to 10 degrees or less of arc around central fixation in the better eye irrespective of corrected visual acuity (equivalent to 1/100 white test object)?' is 'Yes'.

Please enter the date this report is being completed by the ophthalmologist or optometrist. Fill only if 'Is the field of vision constricted to 10 degrees or less of arc around central fixation in the better eye irrespective of corrected visual acuity (equivalent to 1/100 white test object)?' is 'Yes'.

Check this box if the patient's field of vision is not constricted to 10 degrees or less of arc around central fixation in the better eye.

Check this box if the patient's field of vision is constricted to 10 degrees or less of arc around central fixation in the better eye.

Provide specific details regarding the constriction of the field of vision if it is 10 degrees or less of arc around central fixation in the better eye. Fill only if 'Yes' is 'Yes'.

Please provide the fifth diagnosis for the patient.

Please provide the date of onset for the fifth diagnosis. Fill only if 'Fifth Diagnosis' is filled, as it provides the date of onset for the diagnosis.

Please provide a detailed description of the patient's primary diagnosis.

Please enter the date when the diagnosis first became apparent or was confirmed. Fill only if 'Diagnosis Description' is filled, as it provides the date of onset for the diagnosis.

Check this box if the form was completed by an Ophthalmologist.

Check this box if the form was completed by an Optometrist.

Please enter the fourth diagnosis.

Please provide the date when the fourth diagnosis was first identified. Fill only if 'Fourth Diagnosis' is filled, as it provides the date of onset for the diagnosis.

Please enter the family name of the patient.

Please enter the first given name of the patient.

Please enter the second given name of the patient.

Please provide the full name of the ophthalmologist.

Check this box if the opinion is not supported by a report from an ophthalmologist.

Check this box if the opinion is supported by a report from an ophthalmologist, and you will provide details.

Please provide the full details of the ophthalmologist involved in providing the supporting report. Fill only if 'Yes' is 'Yes'.

Check this box if there are no other visual defects.

Check this box if there are other visual defects.

Provide a detailed explanation of any other visual defects observed. Fill only if 'Yes' is 'Yes'.

Provide a detailed account of the patient's prognosis, including any factors influencing their medical outlook.

Please provide a detailed description of the second diagnosis.

Please enter the date when the second diagnosis first became apparent. Fill only if 'Second Diagnosis Description' is filled, as it provides the date of onset for the diagnosis.

Please provide a detailed description of the patient's sixth diagnosis.

Please enter the date when the sixth diagnosis first occurred. Fill only if 'Sixth Diagnosis' is filled, as it provides the date of onset for the diagnosis.

Please provide a detailed description of the third diagnosis.

Please enter the date of onset for the third diagnosis. Fill only if 'Third Diagnosis Description' is filled, as it provides the date of onset for the diagnosis.

Check this box if the patient is not receiving or not likely to receive treatment that will result in significant improvement within the next 2 years.

Check this box if the patient is receiving or likely to receive treatment that will result in significant improvement within the next 2 years.

Please specify the duration or timeframe within which significant improvement is expected, if applicable. Fill only if 'Yes' is 'Yes'.

Provide comprehensive details regarding the treatment, including its nature, expected outcomes, and the basis for anticipating significant improvement within the next two years. Fill only if 'Yes' is 'Yes'.

Check this box if the combined effect of the visual defects does not result in the specified degree of vision impairment.

Check this box if the combined effect of the visual defects does result in the specified degree of vision impairment.

Enter the best corrected visual acuity for the right eye using the Snellen Scale.

Enter the best corrected visual acuity for the left eye using the Snellen Scale.

Check this box if the corrected visual acuity is not less than 6/60 in each eye. Fill only if 'Right Eye Visual Acuity', 'Left Eye Visual Acuity' is answered and the visual acuity is not less than 6/60 in each eye.

Check this box if the corrected visual acuity is less than 6/60 in each eye. Fill only if 'Right Eye Visual Acuity', 'Left Eye Visual Acuity' is answered and the visual acuity is less than 6/60 in each eye.

Check this box if there is no information in the report that might be prejudicial to the patient's physical or mental health if released.

Check this box if there is information in the report that might be prejudicial to the patient's physical or mental health if released.

Indicate if there is information in the report which, if released to the patient, might be prejudicial to their physical or mental health. Fill only if 'Yes' is 'Yes'.

Provide specific details regarding any information in the report that might be prejudicial to the patient's physical or mental health if released. Fill only if 'Yes' is 'Yes'.