[Date of consultation] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write on a single line in the format: DD Month YYYY.)
**Client details**
[Client title and surname] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write on a single line.)
[Client address line 1] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write on a single line.)
[Client address line 2] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write on a single line.)
[Client address line 3] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write on a single line.)
[Client postcode] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write on a single line.)
**Patient details**
Name: [Pet name] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write on a single line.)
Age: [Pet age in years and/or months] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write on a single line.)
Sex: [Pet sex and reproductive status] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write on a single line.)
Species: [Pet species] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. If species is dog, write: "Canine". Write on a single line.)
Breed: [Pet breed] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write on a single line.)
**<u>History</u>**
BIOP: [Duration of pet ownership] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else keep the heading but leave the placeholder blank. Write on a single line.)
Other pets: [Details of other animals in the household] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else keep the heading but leave the placeholder blank. Write on a single line.)
Vaccinations/Flea/Worming: [Current vaccination, flea and worming status] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else keep the heading but leave the placeholder blank. If vaccinations, flea and worming are up to date, write: "Up to date". Write on a single line.)
Diet: [Pet's current diet including food type and feeding routine] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write on a single line.)
Known food allergies: [Known food allergies or dietary intolerances] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else keep the heading but leave the placeholder blank. Write on a single line.)
Travel history: [Travel locations relevant to the clinical case] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else keep the heading but leave the placeholder blank. Write on a single line.)
Other conditions: [Other known medical conditions] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. If no other conditions, write: "No". Write on a single line.)
General health: [Description of general systemic health including any recent symptoms] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write in paragraphs of full sentences.)
Previous ocular conditions/surgeries: [Known past ophthalmic history including previous ocular conditions and surgeries] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. If no previous ocular conditions or surgeries, write: "No". Write on a single line.)
Eye history: [Summary of presenting eye complaint including timeline and nature of symptoms] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write in paragraphs of full sentences.)
Current medications: [Current medications including eye drops and systemic treatments] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. If no current medications, write: "No". Write as a list.)
Previous medication reactions: [Known previous adverse reactions to medications] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else keep the heading but leave the placeholder blank. Write on a single line.)
**<u>Ophthalmic Examination</u>**<u> (OD = right eye, OS = left eye, OU = both eyes)</u>
**Distant examination**
Ocular OD: [Distant examination ocular findings for the right eye (OD)] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else write: "NAD". Write on a single line.)
Ocular OS: [Distant examination ocular findings for the left eye (OS)] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else write: "NAD". Write on a single line.)
Periocular OD: [Distant examination periocular findings for the right eye (OD)] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else write: "NAD". Write on a single line.)
Periocular OS: [Distant examination periocular findings for the left eye (OS)] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else write: "NAD". Write on a single line.)
Head OD: [Distant examination head findings for the right eye (OD)] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else write: "NAD". Write on a single line.)
Head OS: [Distant examination head findings for the left eye (OS)] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else write: "NAD". Write on a single line.)
Visual axis OD: [Distant examination visual axis findings for the right eye (OD)] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else write: "Clear tapetal reflex". Write on a single line.)
Visual axis OS: [Distant examination visual axis findings for the left eye (OS)] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else write: "Clear tapetal reflex". Write on a single line.)
**Tear film parameters and intraocular pressures**
STT OD (mm/min): [STT measurement for the right eye (OD)] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else write: "NAD". Write on a single line.)
STT OS (mm/min): [STT measurement for the left eye (OS)] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else write: "NAD". Write on a single line.)
Tear film quality OD: [Tear film quality for the right eye (OD)] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else write: "Good". Write on a single line.)
Tear film quality OS: [Tear film quality for the left eye (OS)] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else write: "Good". Write on a single line.)
IOP OD (mmHg): [IOP measurement for the right eye (OD)] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else write: "NAD". Write on a single line.)
IOP OS (mmHg): [IOP measurement for the left eye (OS)] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else write: "NAD". Write on a single line.)
**Neuro-ophthalmic examination**
PLR OD: [PLR findings for the right eye (OD)] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else write: "Positive". Write on a single line.)
PLR OS: [PLR findings for the left eye (OS)] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else write: "Positive". Write on a single line.)
Consensual PLR OD: [Consensual PLR findings for the right eye (OD)] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else write: "Positive". Write on a single line.)
Consensual PLR OS: [Consensual PLR findings for the left eye (OS)] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else write: "Positive". Write on a single line.)
Chromatic PLR blue OD: [Chromatic PLR blue findings for the right eye (OD)] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else write: "Positive". Write on a single line.)
Chromatic PLR blue OS: [Chromatic PLR blue findings for the left eye (OS)] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else write: "Positive". Write on a single line.)
Chromatic PLR red OD: [Chromatic PLR red findings for the right eye (OD)] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else write: "Positive". Write on a single line.)
Chromatic PLR red OS: [Chromatic PLR red findings for the left eye (OS)] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else write: "Positive". Write on a single line.)
Menace OD: [Menace response for the right eye (OD)] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else write: "Positive". Write on a single line.)
Menace OS: [Menace response for the left eye (OS)] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else write: "Positive". Write on a single line.)
Dazzle OD: [Dazzle reflex for the right eye (OD)] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else write: "Positive". Write on a single line.)
Dazzle OS: [Dazzle reflex for the left eye (OS)] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else write: "Positive". Write on a single line.)
Vestibulo-ocular reflex OD: [Vestibulo-ocular reflex for the right eye (OD)] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else write: "Positive". Write on a single line.)
Vestibulo-ocular reflex OS: [Vestibulo-ocular reflex for the left eye (OS)] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else write: "Positive". Write on a single line.)
Corneal OD: [Corneal reflex for the right eye (OD)] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else write: "Positive". Write on a single line.)
Corneal OS: [Corneal reflex for the left eye (OS)] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else write: "Positive". Write on a single line.)
Palpebral OD: [Palpebral reflex for the right eye (OD)] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else write: "Positive". Write on a single line.)
Palpebral OS: [Palpebral reflex for the left eye (OS)] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else write: "Positive". Write on a single line.)
**Slit lamp examination**
Eyelids OD: [Eyelids examination findings for the right eye (OD)] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else write: "NAD". Write on a single line.)
Eyelids OS: [Eyelids examination findings for the left eye (OS)] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else write: "NAD". Write on a single line.)
Lacrimal punctae OD: [Lacrimal punctae examination findings for the right eye (OD)] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else write: "NAD". Write on a single line.)
Lacrimal punctae OS: [Lacrimal punctae examination findings for the left eye (OS)] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else write: "NAD". Write on a single line.)
Palpebral conjunctiva OD: [Palpebral conjunctiva examination findings for the right eye (OD)] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else write: "NAD". Write on a single line.)
Palpebral conjunctiva OS: [Palpebral conjunctiva examination findings for the left eye (OS)] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else write: "NAD". Write on a single line.)
Bulbar conjunctiva OD: [Bulbar conjunctiva examination findings for the right eye (OD)] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else write: "NAD". Write on a single line.)
Bulbar conjunctiva OS: [Bulbar conjunctiva examination findings for the left eye (OS)] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else write: "NAD". Write on a single line.)
Third eyelid OD: [Third eyelid examination findings for the right eye (OD)] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else write: "NAD". Write on a single line.)
Third eyelid OS: [Third eyelid examination findings for the left eye (OS)] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else write: "NAD". Write on a single line.)
Cornea OD: [Cornea examination findings for the right eye (OD)] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else write: "NAD". Write on a single line.)
Cornea OS: [Cornea examination findings for the left eye (OS)] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else write: "NAD". Write on a single line.)
Sclera OD: [Sclera examination findings for the right eye (OD)] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else write: "NAD". Write on a single line.)
Sclera OS: [Sclera examination findings for the left eye (OS)] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else write: "NAD". Write on a single line.)
Anterior chamber OD: [Anterior chamber examination findings for the right eye (OD)] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else write: "NAD". Write on a single line.)
Anterior chamber OS: [Anterior chamber examination findings for the left eye (OS)] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else write: "NAD". Write on a single line.)
Iris OD: [Iris examination findings for the right eye (OD)] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else write: "NAD". Write on a single line.)
Iris OS: [Iris examination findings for the left eye (OS)] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else write: "NAD". Write on a single line.)
Iridocorneal angle OD: [Iridocorneal angle examination findings for the right eye (OD)] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else write: "NAD". Write on a single line.)
Iridocorneal angle OS: [Iridocorneal angle examination findings for the left eye (OS)] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else write: "NAD". Write on a single line.)
Lens OD: [Lens examination findings for the right eye (OD)] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else write: "NAD". Write on a single line.)
Lens OS: [Lens examination findings for the left eye (OS)] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else write: "NAD". Write on a single line.)
Vitreous OD: [Vitreous examination findings for the right eye (OD)] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else write: "NAD". Write on a single line.)
Vitreous OS: [Vitreous examination findings for the left eye (OS)] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else write: "NAD". Write on a single line.)
Retina/optic nerve OD: [Retina and optic nerve examination findings for the right eye (OD)] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else write: "NAD". Write on a single line.)
Retina/optic nerve OS: [Retina and optic nerve examination findings for the left eye (OS)] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else write: "NAD". Write on a single line.)
**<u>Additional ophthalmic diagnostics</u>**
(If no information for this section is mentioned in transcript, contextual notes or clinical note, omit the section entirely.)
Fluorescein test OD: [Fluorescein test findings for the right eye (OD)] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else write: "Negative". Write on a single line.)
Fluorescein test OS: [Fluorescein test findings for the left eye (OS)] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else write: "Negative". Write on a single line.)
Jones test OD: [Jones test findings for the right eye (OD)] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else write: "Positive". Write on a single line.)
Jones test OS: [Jones test findings for the left eye (OS)] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else write: "Positive". Write on a single line.)
Ultrasound OD: [Ultrasound findings for the right eye (OD)] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write on a single line.)
Ultrasound OS: [Ultrasound findings for the left eye (OS)] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write on a single line.)
**Obstacle course:** (If no information for this section is mentioned in transcript, contextual notes or clinical note, omit the section entirely.)
Photopic (light) conditions: [Obstacle course results under photopic conditions] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else keep the heading but leave the placeholder blank.)
Scotopic (dark) conditions: [Obstacle course results under scotopic conditions] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else keep the heading but leave the placeholder blank.)
**Laboratory diagnostics:** (If no information for this section is mentioned in transcript, contextual notes or clinical note, omit the section entirely.)
[Laboratory diagnostic results including test type and findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
**Imaging:** (If no information for this section is mentioned in transcript, contextual notes or clinical note, omit the section entirely.)
[Imaging modality and associated findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
**<u>General physical examination:</u>** (If no information for this section is mentioned in transcript, contextual notes or clinical note, omit the section entirely.)
Demeanour: [Demeanour finding] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else keep the heading but leave the placeholder blank.)
MM: [Mucous membrane finding] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else keep the heading but leave the placeholder blank.)
CRT: [Capillary refill time finding] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else keep the heading but leave the placeholder blank.)
Thoracic auscultation: [Thoracic auscultation finding] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else keep the heading but leave the placeholder blank.)
Abdominal palpation: [Abdominal palpation finding] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else keep the heading but leave the placeholder blank.)
Lymph nodes: [Lymph node finding] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else keep the heading but leave the placeholder blank.)
**<u>Clinical photographs</u>**
Right eye: [Image reference or description of right eye clinical photograph] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as image caption on a single line.)
Left eye: [Image reference or description of left eye clinical photograph] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as image caption on a single line.)
Right fundus: [Image reference or description of right fundus photograph] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as image caption on a single line.)
Left fundus: [Image reference or description of left fundus photograph] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as image caption on a single line.)
Profile: [Image reference or description of profile photograph] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as image caption on a single line.)
**<u>Diagnosis</u>**
[Clinician's explicitly stated ophthalmic diagnoses for one or both eyes] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Never invent or infer a diagnosis. Write in the format: Eye affected – diagnosis. List each diagnosis on a new line.)
**<u>Recommended diagnostic and treatment plan</u>**
[Recommended treatments including topical medications, systemic treatments or surgical interventions] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write in the format: Eye affected – treatment. List each treatment on a new line.)
**<u>Summary</u>**
[Clinical summary of findings, diagnostic reasoning, treatment plan and prognostic considerations] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write in paragraphs of full sentences.)
**<u>Next follow-up examination</u>**
[Recommended timeframe or date for next follow-up] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write on a single line.)
Thank you for referring this case, it was a pleasure looking after [insert pet name] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.). Please feel free to contact me by phone or email in case of any questions. Our contact telephone number is [contact number] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.), alternatively you can email [email address] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
[Referring clinician full name and qualifications] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write on a single line.)
[Referring clinician professional titles or accreditations] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write on a single line.)
[Referring clinician role and training status] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write on a single line.)
Supervised by:
[Supervisor full name and qualifications] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write on a single line.)
[Supervisor professional titles or accreditations] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write on a single line.)
[Supervisor role or position] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write on a single line.)
