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Normann Ola
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1. Client information
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2. Findings
3. Images and attachments
4. Completion
Patient
Client Id
Personal Id
Date of birth
/
/
First name
Last name
Sex
Male
Female
Street address
Postal code
City
Primary doctor
Phone
SMS
Primary doctor
Primary doctor
Brief description of the problem (Why should the patient be referred?)*
Brief description of the problem (Why should the patient be referred?)*
Anamnesis
Glaucoma
AMD
Amblyopia
Retinal diseases
Other
None
Current and past diseases
Eye disease
HBT
Metabolic discorder
DM 1
DM 2
Other
None
Symptoms*
Reduced visus
Visual disturbances
Scotomas / shadows
Blured vision
Eye pain
Other
None
Duration*
Acute
< 4 weeks
< 6 months
> 6 months
Not applicable
Visus and refraction
Visus
Manual Measurement
OD
OS
Both
SC
CC
Refraction
OD
sf
cyl
axis
'The sf value must be between -15 and 15'
'The Cyl value must be between -12 and 0'
'The Axis value must be between 0 and 180'
OS
Both
ADD
EFRON lens complication
Conjunctival redness (Hyperemia)
OD
1
2
3
4
5
OS
1
2
3
4
5
Refraction
OD
1
2
3
4
5
OS
1
2
3
4
5
LIPCOF
OD
1
2
3
4
5
OS
1
2
3
4
5
Anatomical assessment
Eyelid
Eyelid edge
Conjunctiva
Cornea
Anterior segment
'MGD'
Tear Volume
Schirmer II
Red phenol
SM Tube
Tear prism
MMP
OD
OS
Other*
Right eye
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Screenshot
Record screen
Binocular
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Screenshot
Record screen
Left eye
JPG, JPEG, PNG or PDF files can be uploaded
Add image
Screenshot
Record Screen
Other*
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