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    Plaquenil Evaluation 2011

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    strawberry88328
    This document is a form for evaluating a patient taking hydroxychloroquine (Plaquenil) that records their name, referring physician, Plaquenil dose and duration, weight, eye exam results including visual acuity and macular fields, need for additional testing, follow up recommendations, and space for comments.

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    Plaquenil Evaluation 2011

    Uploaded by

    strawberry88328
    145 views1 page
    This document is a form for evaluating a patient taking hydroxychloroquine (Plaquenil) that records their name, referring physician, Plaquenil dose and duration, weight, eye exam results including visual acuity and macular fields, need for additional testing, follow up recommendations, and space for comments.

    Original Description:

    plaquenil

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    This document is a form for evaluating a patient taking hydroxychloroquine (Plaquenil) that records their name, referring physician, Plaquenil dose and duration, weight, eye exam results including visual acuity and macular fields, need for additional testing, follow up recommendations, and space for comments.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as pdf or txt
    145 views1 page

    Plaquenil Evaluation 2011

    Uploaded by

    strawberry88328
    This document is a form for evaluating a patient taking hydroxychloroquine (Plaquenil) that records their name, referring physician, Plaquenil dose and duration, weight, eye exam results including visual acuity and macular fields, need for additional testing, follow up recommendations, and space for comments.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as pdf or txt
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    Hydroxychloroquine (Plaquenil) Evaluation

    Patient Name Referring Physician Consultant Optometrist Date Plaquenil dose / / mg Number of years taking HCQ Patients Weight Estimated Lean Weight Fundus exam Normal Other lbs. lbs. D.O.B.

    Acuity Right 20/_____ Left 20/_____

    Macular Visual Field Testing (10-2)

    Normal

    Other

    Additional Testing

    Recheck

    Annually

    Other

    Comments:

    Thank you very much for entrusting us with the eye care of your patient.

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