Suspect Glaucoma Direct Referral Form

Norfolk & Norwich University Hospitals NHS Foundation Trust
Suspect Glaucoma Direct Referral Form
To be sent by Optometrist Direct to Ophthalmology Department.
Fax: 01603 289917
Patient Details
Title (Dr Mr Mrs Miss Ms)
Surname
Other Names
Address
DoB
Phone
Post Code
Hospital Number (if known)
Date of test:
Details of current sight test
Vision
Sph
Cyl
Axis
Prism
Add
VA
Near VA
RE
LE
Clinical findings: Reasons for suspecting glaucoma
Please circle or complete
Right Eye
Left Eye
Visual fields performed?
Yes / No / Unreliable
Yes / No / Unreliable
Visual field (enclose plot)
Normal / Suspect / Abnormal
Normal / Suspect / Abnormal
Defect confirmed on repeat?
Yes / Not repeated
Yes / Not repeated
C:D ratio / vertical disc size
/
mm
/
Right Eye
IOP this visit:
mmHg
Time:
Tonometer
mm
Normal / Suspect / Abnormal
Normal / Suspect / Abnormal
Van Herrick AC grading
Open (III-IV) / Narrow (I-II)
Open (III-IV) / Narrow (I-II)
If narrow – any symptoms?
None / brow-ache / haloes / other:
Perkins
Other: ________________
Previous IOP:
mmHg
Other signs/risk factors (e.g. +ve FH, disc haem, PXF, PDS etc)
Patient referred from referral refinement scheme?
Yes / No
Other comments / info:
OHT / Suspect Glaucoma / Narrow AC Angles / Other:
Optometrist (PRINT):
Name:
Signature:
Date:
Additional Information from GP
PMH/ Medication
GP
Signature:
Print:
Name &
Address of
GP
Date:
Name & Address
of Optometrist
Fax 1 copy to NNUH
Forward 1 copy to the GP
Goldmann
Used
Date & Time:
Reason for referral:
mmHg
NCT model: ____________
Optic Disc / Neuro-retinal rim
Accredited for glaucoma referral refinement scheme? Yes / No
Left Eye
Retain 1 copy for your records
mmHg

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