The Pupil Project

Third year patient log form

2011-2012

(Version 8.9)

Center (site)
Attending
Student
Graduation year
Student e-mail address* (UMSL Email ID required)
Term*

Data from (start of semester)

To (end of semester)

AGE	# patients
0-18
19-39
40-64
65 -

Note: Please include the number of individual patient observations and patients screened in these totals above. The table above should contain the total number of patients that you have seen. These data are then detailed in the table at the right. >>>>>>>>>

The totals in the 2 tables must be the same.

**PATIENT ENCOUNTER TYPE**
	COMP	FU	OBSERV

PC

CL(winter semester)

PEDS/BV (winter semester)

LV

EHMS

SCREENING (enter in OBSERV column)

**Dispensary Contacts**
Spectacle Dispensary Encounters		( Enter 0 if no Encounters)

**PRIMARY DIAGNOSES- max 3/patient**
Refractive error	367
Eyelid/lacrimal	373/375
Conjunctivitis	372
Cornea	371
Iris/ciliary body	364
Glaucoma	365
Lens/vitreous	366/379
Retina/choroid	361/363
Oculomotor	378
Globe/orbit	360
Neuro-ophth	377

**TREATMENTS-**max 3/patient
SPEC
CL
VT
LV
Rx MEDS
OTC MEDS
LASER(pre&post testing)
INJECTABLES
REFERRAL
OTHER

Questions? e-mail Dr. Timothy Wingert, Chief, Primary Care Services
Questions? e-mail Edna Major, Administrative Assistant

RGarzia / BRegoti / LPickett / WFLong 08/20/2005

Webmaster: Dr. Ralph Garzia & Manasee Punjani
Last Updated: June - 17 - 2010