Screening Form

GENERAL INFORMATION

First Name(*)
Please let us know your name.

Last Name(*)
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Age(*)
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Gender(*)
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DOB(*)

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Occupation(*)
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Next Of Kin(*)
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Phone Number(*)
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Your Email(*)
Please let us know your email address.

Name Of Current Physician(*)
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Additional Information(*)
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Patient Has NHIF / Insurance Coverage?(*)
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ID Number(*)
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Screening Date(*)

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Location Of Screenng(*)
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BRIEF MEDICAL HISTORY

Known Diabetic(*)
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Comment

High Blood Pressure(*)
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Comment

Cardiovascular Disease(*)
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Comment

Any Breathing Difficulties(*)
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{COPD/Asthma}(*)
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Comment

Known Cancer / Does anyone in family have cancer(*)
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Comment

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Comment

Others(*)
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Specify(*)
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EYE SCREENING FORM

VA WITH GLASSES

Left Eye(*)
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Right Eye(*)
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VA WITHOUT GLASSES

Left Eye
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Right Eye
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Refraction(*)
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VALUE FOR REFRACTION

Uncorrected Vision
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Sphere
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Cylinder
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Axis
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Vision
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P.H
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Add
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Doctors Eye Consultation(*)
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Doctor Comments(*)
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Cataract Surgery Required(*)
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Glaucoma(*)
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Keratoconus(*)
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Squint(*)
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Other eye surgery required?
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VITAL ASSESSMENTS

Weight
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KGS

Height
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CM

BMI Score
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Blood Sugar
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mmol/L

BLOOD PRESSURE

Systolic
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mmHg

Diastolic
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mmHg

Pulse
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B/m

 
DOCTOR COMMENTS

Doctor Remarks
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Referral
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Facility(*)
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