C
ATTENDING PHYSICIAN SECTION
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Connued
PRIOR MEDICATION OR TREATMENT
Has the paent ever used medicaon or received treatment for this medical condion? Yes No
If not, please explain:
If so, please list any medicaon already used or any treatment already received for this medical condion:
• Make sure to ll out all secons so we can process the request faster. If any informaon is missing, we will send the form back to the member.
• In order to consider any diagnosis not menoned on this form, we need supporng documents (clinical pracce guidelines, clinical studies, etc.) that jusfy the drug’s
use in the given context.
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Diagnosis
Neovascular (wet) age-related macular degeneraon
Visual impairment due to macular edema secondary to central renal vein occlusion (CRVO)
Visual impairment due to macular edema secondary to branch renal vein occlusion (BRVO)
Visual impairment due to diabec macular edema (DME)
Choroidal neovascularizaon secondary to pathological myopia
Other therapeuc indicaon(s) - Please specify:
Informaon relang to neovascular (wet) age-related macular degeneraon
Opmal visual acuity, aer correcon, between 6/12 and 6/96: Yes No
Linear dimension of the lesion less than or equal to 12 disc areas: Yes No
Presence of signicant permanent structural damage to the centre of the macula: Yes No
Has the disease progressed in the last three months? Yes No
If so, please specify: Conrmed by renal angiography Conrmed by opcal coherence tomography Conrmed by recent changes in visual acuity
Treatment administered in conjucon with Verteporn (Visudyne
®
): Yes No Which eye was treated? Right eye Le eye Both eyes
Informaon relang to diabec macular edema
Hemoglobin A1c: % Opmal visual acuity, aer correcon, between 6/9 and 6/96: Yes No
What is the thickness of the central rena? Is photocoagulaon also indicated? Yes No
Informaon relang to choroidal neovascularizaon secondary to pathological myopia
Axial length of the eyeball: mm
Myopia is greater than -6 diopters: Yes No
Opmal visual acuity aer correcon is between 6/9 and 6/96: Yes No
There is intrarenal or subrenal uid or an acve leak due to a choroidal neovascularizaon lesion: Yes No
If so, please specify: Observed by renal angiography Observed by opcal coherence tomography
Informaon relang to visual impairment due to macular edema secondary to renal vein occlusion (RVO) or to branch renal vein occlusion (BRVO)
Opmal visual acuity, aer correcon: Between 6/9 and 6/96 Between 6/12 and 6/120
What is the thickness of the central rena? Is there absence of aerent pupillary defect: Yes No
Prescripon renewal
Necessary informaon to assess response to treatment aer three months or more. Please include the results of the following 2 exams:
Le eye
Assessement of visual acuity measured with Snellen chart
Date : Stabilizaon Improvement Degradaon
Assessment of macular edema with an opcal coherence tomography
Date : Stabilizaon Improvement Degradaon
YYYY MM DD
YYYY MM DD
Right eye
Assessement of visual acuity measured with Snellen chart
Date : Stabilizaon Improvement Degradaon
Assessment of macular edema with an opcal coherence tomography
Date : Stabilizaon Improvement Degradaon
YYYY MM DD
YYYY MM DD
YYYY MM DD
MEDICATION OR TREATMENT NAME
OUTCOME
Name:
Dose:
Name:
Dose:
Name:
Dose:
Name:
Dose:
Ineciency Intolerance Contraindicaon
Specify:
Ineciency Intolerance Contraindicaon
Specify:
Specify:
Specify:
Ineciency Intolerance Contraindicaon
Ineciency Intolerance Contraindicaon
TREATMENT PERIOD
From:
To:
From:
To:
From:
To:
From:
To:
YYYY MM DD
YYYY MM DD
YYYY MM DD
YYYY MM DD
YYYY MM DD
YYYY MM DD
YYYY MM DD
