This is a dictation template to provide a reminder of the information required to complete the referral. The fields in red are mandatory and must be completed on the referral protocol.
Optometry Referral Details
Date of Referral: [Date]
Priority: [Routine]
Patient history and details: [Text]
Patient symptomatic:
- Yes
- No
Cataract Information
Lifestyle affected:
- Yes
- No
Wants Surgery:
- Yes
- No
Cataract leaflet given:
- Yes
- No
AMD present:
- Yes
- No
- Don’t know
Ocular examination – External/Internal
Comment right eye: [Text]
Comment left eye: [Text]
Tonometry (value between 0-50mmHg)
Applanation:
- Yes
- No
- Not possible
Right: [Text]
Left: [Text]
Relative afferenct pupilary defect:
- Yes
- No
Fields affected:
- Yes
- No
Last eye test
Date of test: [Date]
Right acuity:
- 6/4.5
- 6/5
- 6/6
- 6/9
- 6/12
- 6/18
- 6/24
- 6/36
- 6/60
- 3/60
- 1/60
- CF
- HM
- P of L
- No P of L
Left acuity:
- 6/4.5
- 6/5
- 6/6
- 6/9
- 6/12
- 6/18
- 6/24
- 6/36
- 6/60
- 3/60
- 1/60
- CF
- HM
- P of L
- No P of L
Refraction Details
Right Vision
R Sph: +/-
R Cyl: +/-
R Sph: [Between 0 – 25]
R Cyl: [Between 0 – 15]
R Axis: [Between 0 – 180]
R VA:
- 6/4.5
- 6/5
- 6/6
- 6/9
- 6/12
- 6/18
- 6/24
- 6/36
- 6/60
- 3/60
- 1/60
- CF
- HM
- P of L
- No P of L
R PH VA:
- 6/4.5
- 6/5
- 6/6
- 6/9
- 6/12
- 6/18
- 6/24
- 6/36
- 6/60
R Add: [Between 1 – 4]
R NVA:
- N4.5
- N5
- N6
- N8
- N9
- N10
- N12
- N14
- N18
- N24
- N36
- N48
- NIL
Left Vision
L Sph: +/-
L Cyl: +/-
L Sph: [Between 0 – 25]
L Cyl: [Between 0 – 15]
L Axis: [Between 0 – 180]
L VA:
- 6/4.5
- 6/5
- 6/6
- 6/9
- 6/12
- 6/18
- 6/24
- 6/36
- 6/60
- 3/60
- 1/60
- CF
- HM
- P of L
- No P of L
L PH VA:
- 6/4.5
- 6/5
- 6/6
- 6/9
- 6/12
- 6/18
- 6/24
- 6/36
- 6/60
L Add: [Between 1 – 4]
L NVA:
- N4.5
- N5
- N6
- N8
- N9
- N10
- N12
- N14
- N18
- N24
- N36
- N48
- NIL
Ophthalmology Cataract Guideline