info@lionsloresho.org
Search
Home
About Us
Mission & Vision
Board of Management
Our Supporters
Donate
Make A Donation
Partner With Us
Corporate Tie-Ups
Corporate Eye Check-Ups
Pledge Your Eyes
Services
Eye Care Services
General Out Patient & Executive Clinic
Vitreo-Retinal Clinic
Glaucoma Clinic
LASIK
Optical Centre
Low Vision Clinic
Pediatric Ophthalmology
Orbital Oculoplasty
Eye Glossary
Squint Clinic
Dental Unit
Hearing Unit
Eye Bank
Community Eye Care
Laboratory Services
Training
Diabetes Care Center
Common Foot Issues for Diabetics
Staff Mail
FAQs
Contact Us
OPTHALMIC NURSES SYMPOSIUM
Screening
News & Events
Health Insight
What Do I Do If i Have Keratoconus?
4 Ways Diabetes Can Affect Your Eyes
Regaining Your Night Vision After Cataract Surgery
Ageing and Your Eyes: When Should You See an Ophthalmologist?
What Is Glaucoma? Causes and Symptoms
When Is It Time to See an Audiologist?
Lasik Eye Surgery
Why Diabetes Check-Ups are Important in Your Care
Contact lenses
Floaters in the Eye; Should I be worried?
Childhood Eye Injuries
What is the Primary Open Angle of Glaucoma?
Upcoming Trainings
Upcoming Events
Gallery
Video Gallery
Testimonials
“Cataract Surgery Changed My Life!”
Home
About Us
Mission & Vision
Board of Management
Our Supporters
Donate
Make A Donation
Partner With Us
Corporate Tie-Ups
Corporate Eye Check-Ups
Pledge Your Eyes
Services
Eye Care Services
General Out Patient & Executive Clinic
Vitreo-Retinal Clinic
Glaucoma Clinic
LASIK
Optical Centre
Low Vision Clinic
Pediatric Ophthalmology
Orbital Oculoplasty
Eye Glossary
Squint Clinic
Dental Unit
Hearing Unit
Eye Bank
Community Eye Care
Laboratory Services
Training
Diabetes Care Center
Common Foot Issues for Diabetics
Staff Mail
FAQs
Contact Us
OPTHALMIC NURSES SYMPOSIUM
Screening
News & Events
Health Insight
What Do I Do If i Have Keratoconus?
4 Ways Diabetes Can Affect Your Eyes
Regaining Your Night Vision After Cataract Surgery
Ageing and Your Eyes: When Should You See an Ophthalmologist?
What Is Glaucoma? Causes and Symptoms
When Is It Time to See an Audiologist?
Lasik Eye Surgery
Why Diabetes Check-Ups are Important in Your Care
Contact lenses
Floaters in the Eye; Should I be worried?
Childhood Eye Injuries
What is the Primary Open Angle of Glaucoma?
Upcoming Trainings
Upcoming Events
Gallery
Video Gallery
Testimonials
“Cataract Surgery Changed My Life!”
Home
Contact Us
Screening
Follow via Facebook
Follow via Twitter
Follow via Google+
Follow via LinkedIn
Screening Form
GENERAL INFORMATION
First Name
(*)
Please let us know your name.
Last Name
(*)
Please let us know your name.
Age
(*)
Invalid Input
Gender
(*)
Male
Female
Invalid Input
DOB
(*)
Invalid Input
Occupation
(*)
Invalid Input
Next Of Kin
(*)
Invalid Input
Phone Number
(*)
Invalid Input
Your Email
(*)
Please let us know your email address.
Name Of Current Physician
(*)
Please write a subject for your message.
Additional Information
(*)
Smoker
Alcohol
Invalid Input
Patient Has NHIF / Insurance Coverage?
(*)
Yes
No
Invalid Input
ID Number
(*)
Invalid Input
Screening Date
(*)
Invalid Input
Location Of Screenng
(*)
Invalid Input
BRIEF MEDICAL HISTORY
Known Diabetic
(*)
Yes
No
Invalid Input
Invalid Input
Comment
High Blood Pressure
(*)
Yes
No
Invalid Input
Invalid Input
Comment
Cardiovascular Disease
(*)
Yes
No
Invalid Input
Invalid Input
Comment
Any Breathing Difficulties
(*)
Yes
No
Invalid Input
{COPD/Asthma}
(*)
Yes
No
Invalid Input
Invalid Input
Comment
Known Cancer / Does anyone in family have cancer
(*)
Yes
No
Invalid Input
Invalid Input
Comment
Invalid Input
Comment
Others
(*)
Yes
No
Invalid Input
Specify
(*)
Invalid Input
EYE SCREENING FORM
VA WITH GLASSES
Left Eye
(*)
6/60
6/36
6/24
6/18
6/12
6/9
6/6
6/5
CF5m
CF4m
CF3m
CF2m
CF1m
Hm
PL
NV
Invalid Input
Right Eye
(*)
6/60
6/36
6/24
6/18
6/12
6/9
6/6
6/5
CF5m
CF4m
CF3m
CF2m
CF1m
Hm
PL
NV
Invalid Input
VA WITHOUT GLASSES
Left Eye
6/60
6/36
6/24
6/18
6/12
6/9
6/6
6/5
CF5m
CF4m
CF3m
CF2m
CF1m
Hm
PL
NV
Invalid Input
Right Eye
6/60
6/36
6/24
6/18
6/12
6/9
6/6
6/5
CF5m
CF4m
CF3m
CF2m
CF1m
Hm
PL
NV
Invalid Input
Refraction
(*)
Yes
No
Invalid Input
VALUE FOR REFRACTION
Uncorrected Vision
Invalid Input
Sphere
Invalid Input
Cylinder
Invalid Input
Axis
Invalid Input
Vision
Invalid Input
P.H
Invalid Input
Add
Invalid Input
Doctors Eye Consultation
(*)
Yes
No
Invalid Input
Doctor Comments
(*)
Invalid Input
Cataract Surgery Required
(*)
Yes
No
Invalid Input
Glaucoma
(*)
Yes
No
Invalid Input
Keratoconus
(*)
Yes
No
Invalid Input
Squint
(*)
Yes
No
Invalid Input
Other eye surgery required?
Invalid Input
VITAL ASSESSMENTS
Weight
Invalid Input
KGS
Height
Invalid Input
CM
BMI Score
Invalid Input
Blood Sugar
FBS
RBS
Invalid Input
Invalid Input
mmol/L
BLOOD PRESSURE
Systolic
Invalid Input
mmHg
Diastolic
Invalid Input
mmHg
Pulse
Invalid Input
B/m
DOCTOR COMMENTS
Doctor Remarks
Invalid Input
Referral
Yes
No
Invalid Input
Facility
(*)
Lions DCC
Mp Shah DCC
Village Market DCC
Town Clinic DCC
Local Facility
District Hospital
Invalid Input
REACH OUT TO US
Book Appointment
Our Patients Testimonials
Contact Us
/
Location Map
Visitor's Counter
Total Site Visit :
1
3
1
0
1
8
Contact Centre
LSEH
About Us
Board of Management
Our Supporters
Partner With Us
Contact Us
CORE SERVICES
Eye Bank
Dental Unit
Hearing Unit
Community Eye Care
Training
Newsletter SignUp
By subscribing to our mailing list you will always be updated with the latest news from us.
We do not spam!
JavaScript is currently disabled.
Please enable it for a better experience of
Jumi
.
We use cookies to improve our website. Cookies used for the essential operation of this site have already been set. For more information visit our
Cookie policy
.
I accept cookies from this site.
Agree