Low Vision Record Template

Low Vision Assessment Subjective Patient Name: "John Smith" Date of Birth: 15 March 1950 Gender: Male NHS Number: 1234567890 Address: 123 Vision Lane, Sight Town, ST1 2AB Telephone: 01234 567890 Referral and Access New or existing Low Vision Patient: New Referral Source: GP Transportation: Public Transport Waiting Time: 2 weeks Ocular History Eye Conditions: Age-related macular degeneration diagnosed 5 years ago, progressive vision loss Previous Ophthalmic Interventions: Cataract surgery in both eyes Medical History General Health: Hypertension, Type 2 Diabetes Medications: Lisinopril, Metformin Social and Functional History Social Situation: Lives with spouse, supportive family Reported Difficulties: Difficulty reading small print, issues with mobility in low light Current Support: Receives assistance from local vision support group Patient's Goals: Improve reading ability and enhance mobility Objective Visual Acuity Unaided Distance VA: Right Eye: 6/60 Left Eye: 6/48 Aided Distance VA: Right Eye: 6/36 Left Eye: 6/30 Near VA: N12 at 40 cm Contrast Sensitivity Test Used: Pelli Robson Method: Binocular Results: Binocular: 1.25 Log CS Current Spectacles Right Eye: +2.00 -1.00 x 90 Left Eye: +2.50 -0.75 x 85 Date of Last Eye Exam: 1 November 2023 Low Vision Assessment Current LVAs: Handheld magnifier, VA improved to N8 LVAs Tried: Stand magnifier, VA achieved N6 LVAs Dispensed: Stand magnifier Risk Factors Sensory Impairments: None Living Situation: Lives with family Mobility: Uses a cane for stability Safety: Difficulty with medication management Psychosocial: Signs of mild depression Plan Spectacle/Tint Prescription: Prescribed reading glasses with +3.00 add Advice Given: Recommended increased lighting, use of contrast-enhancing filters, and eccentric viewing techniques Referrals: Referred to Ophthalmologist for further evaluation, advised to contact Social Services for additional support Registration: Advised on registration as SI Follow-up Appointment: 6 months Practitioner Notes Additional Observations: Patient motivated and receptive to using low vision aids "Practitioner Signature:" Dr. Iain Mellis "Date:" 1 November 2024