Date as of July 01, 2013

REC-006-Jul2013-Rev0

DEPARTMENT OF HEALTH
Integrated Chronic Non-Communicable Disease Registry System

1 National Registry No.

Prevention of Blindness Registry Form

Note: Please put N/A for Not Applicable fields. Kindly refer to the instruction on how to fill up the form at the back.
GENERAL DATA
2 Name of Reporting Health Facility
3 Hospital Patient ID No.
4 Hospital Registry No.

Out-patient
Referred, Referring Facility ________________________
Walk-in

6 Type of Patient

7 Name of Patient*

Last Name

First Name

In Patient
Referred, Referring Facility _____________________
Walk-in

8 Sex*
Female
Male

____________________ __________________ ____________________

5Hospital Case No.

9 Civil Status
Single
Widow/er
Co-Habitation
Divorced

Middle Name

Married
Separated
Annulled

10 Mothers Maiden Name ________________________ ______________________ _______________________

Last Name

First Name

Middle Name

11 Permanent Address
____________________ _________ _____________________ _____________________ _________________
Number & Street Name

Region

Province

City/Municipality

12 Landline #
__________

Barangay

Zip Code

11a Temporary Address

____________________ _________ _____________________ _____________________ _________________
Number & Street Name

13 Birth Date *
____/____/____
mm dd yyyy

Region

Province

City/Municipality

14 If Date of Birth
____Yrs ____ Mos ____ Days

20 Highest Educational Attainment

24 Contact Person (in case of emergency)

Zip Code

22 Company

_________________, ___________________, ____________

Last Name

First Name

Region

Province

City/Municipality

16 Religion

18 Race

17 Nationality

19 Ethnicity

23 PhilHealth #

23a Common
Reference #

24b Landline #

24d Email Address

Middle Name

24a Address
_________________ _________ _________________ _________________ _______________ __________
Number & Street Name

12c Email Address

__________

Barangay

15 Place of Birth (Province,City/Municipality)

21 Occupation

12a Mobile #

Barangay

24c Mobile #

Zip Code

PATIENT HISTORY

25 Date of Consultation/ Admission

____/____/_____
mm

dd

26 Chief Complaint:

yyyy

27 History of Vision Loss

28 Degree of Vision Loss:

Congenital present at birth

Unaided

Acquired

with Glasses

Can be tested
Low Vision
Blind
Cannot be tested: Believed blind
Believed not blind
Refraction
30 Causes of Low Vision or Blindness
30a Refractive Error
Myopia
Hyperopia
Astigmatism
Mixed
Presbyopia
Amblyopia
30b Disorders
Physical, Disorganized or Absent Globe
Cataract (if checked, answer item nos. 33-36)
Uncorrected Aphakia
Corneal Opacity
Anterior Uveitis
Glaucoma
Optic Atrophy
Retinopathy
Chorioretinitis
Macular Degeneration
Retinal Detachment
Tumors

Right Eye

Left Eye

Acute

Gradual

Unknown

29 Previous Eye Surgery

No evidence of Surgery
Not Assessed
Type of Previous Surgery
Eyelid
Cataract
Glaucoma
Couching
Others, specify _____________________
30c Underlying Causes

Right Eye

Left Eye

Right Eye

Left Eye

No listed underlying cause

Congenital/Neonatal Factor
Onchocerciasis
Measles/Vitamin A Deficiency
Surgical Procedure
Trachoma
Diabetes
Tuberculosis (TB)
Traditional Medicine
Infection
Carcinoma
Other Causes of Retinopathy
Retinopathy of Prematurity
Others, specify ____________

Right Eye

Left Eye

Date as of July 01, 2013

REC-006-Jul2013-Rev0

DEPARTMENT OF HEALTH
Integrated Chronic Non-Communicable Disease Registry System

Others, specify ___________________

Not Examined
31 Prognosis of Vision Loss:
Treatable
Guarded/Progressive
Untreatable
Unknown
32 Prosthetic Device
Eye Glasses
Contact Lenses
Prosthetic Eye(s)
Other (specify) __________________________
For CATARACT Case

33 Type of Cataract
Primary
Senile/Age related
Congenital
Developmental
Secondary
Trauma
Infection
Surgery-induced
Glaucoma
Others, specify_________

34 Visual Acuity: Pre-operative

Best Corrected Visual Acuity

36 Type of Cataract surgery

Right Eye

35 Date of Operation____/____/_____
mm

35a Eye Operated

dd

Right Eye
With
Without
IOL
IOL

Left Eye

yyyy

Right Left Both Eyes

Left Eye
With
Withou
IOL
t IOL

ICCE

ECCE

SICS

PHACO

IOL

35b Name of Surgeon _____________________________

37 Final Diagnosis: ICD-1O Code

38 Disposition Admitted
Discharge Against Medical Advice
Discharged
Treated and Sent Home
Transferred
Absconded
39 Consultant in-charge _________________, ___________________, ____________
Last Name

First Name

Middle Name

____________________

39c Landline #

39e Email Address

Department

39a License/PRC No:____________________________

39b Address _________________ _________ _________________ _________________ ____________ _______
Number & Street Name

Region

Province

City/Municipality

40 Completed By _________________, ___________________, __________________

Last Name

First Name

Barangay

____________________

Middle Name

Region

Province

City/Municipality

40b Landline #

40d Email Address

40c Mobile #

41 Date Completed
____/____/___

Department

40a Address
_________________ _________ _________________ _______________ ___________ _______
Number & Street Name

39d Mobile #

Zip Code

Barangay

Zip Code

mm dd

yyyy

DEPARTMENT OF HEALTH
Integrated Chronic Non-Communicable Disease Registry System

Date as of July 01, 2013

REC-006-Jul2013-Rev0

Instructions on how to fill-up the Prevention of Blindness Registry Form

No.
1
2

Field Name
National Registry No.

Instruction
This is a system-generated number assigned by the NEISS software. Once the injury report is encoded into the system, copy the systemgenerated number and write on the blank area.
Write the name of the Hospital who is submitting the report.

3
4
5
6
7

Name of Reporting Health

Facility
Hospital Patient ID No.
Hospital Registry No.
Hospital Case No.
Type of Patient
Name of Patient

Sex

Check the appropriate box for the sex of the injured by birth.

9
10

Civil Status
Mothers Maiden Name

11
11a
12
12a
12b
13
14
15
16
17
18

Permanent Address
Temporary Address
Landline #
Mobile #
Email Address
Birth Date
If Date of Birth is not available
Place of Birth
Religion
Nationality
Race

Check the appropriate box for the civil status of the injured. Not legally separated still to be considered as Married
Write the mothers name of the patient before marriage. The full middle name must be entered. If there is no middle name, write
N/A.
Write the patients permanent address - House No. and Street, Barangay, Municipality/City and Province
Write the patients temporary address - House No. and Street, Barangay, Municipality/City and Province
Write the patients contact details such as landline number, mobile number and email address.

19
20

Ethnicity
Highest Educational Attainment

21
22
23
23a

Occupation
Company
PhilHealth #
Common Reference #

24

Contact Person (in case of

emergency) , Address, Landline #,
Mobile #, Email Address
Date of Consultation/Admission
Chief Complaint:
History of Vision Loss
Degree of Vision Loss:

24a-24d

25
26
27
28

Write the hospital-based issued I.D. or number to uniquely identify the patient.
Write the hospital-based issued registry number to uniquely identify the patient.
Write the hospital-based issued case number uniquely identify each case or incidence.
Check the button for the corresponding type of patient the victim is.
Write the patients Last name, First name and Middle name in the appropriate spaces provided.

Write the date of birth of the patient in the format mm/dd/yyyy (eg. July 1, 1970 should be entered as 07/01/1970 )
If date of birth cannot be provided then enter in the space provided the age of the patient in years or months or days.
Write the Province and the City/Municipality where the patient was born.
Write the patients religion.
Write the patients nationality.
Write the race of the person which describes the skin color, i.e. American (Red Skin), Caucasian (White Skin), Ethiopian (Black Skin),
Malay (Brown Skin), Mongolian (Yellow Skin)
Write the ethnicity of the patient, e.g. Asian, Indian, Pacific Islander, or others
Write the highest educational attainment of the patient whether he is elementary, high school, vocational, college, post graduate, or
others.
Check the appropriate box for the occupation of the injured.
Write the name of the company where the injured is working.
Write the PhilHealth Number of the patient if he is a member or a dependent.
Write the Unified Multi-Purpose ID Common Reference No. if the patient has any. (UMID CRN can be found in the upgraded,
present government IDs such as the SSS, GSIS and Philippine Health Insurance Corp. UMID-CRN is the primary identifier of an
individual transacting business or availing of services from any government agency.)
Write the name of the person that may be contacted should any emergency may happen to the patient.
Write the address and other contact details such as landline number, mobile number and the email address.
Write the date of the patients Consultation/Admission
Write the patients chief complaint
Check the appropriate box corresponding to the patients History of Vision Loss.
Check the appropriate box corresponding to the Degree of Vision Loss the patient has. Please refer to the chart produced by the World
Health Organization's Programme for Prevention of Blindness illustrates the different categories of vision impairment:
Category of Visual
Impairment
1

4
5
9

Visual Acuity with BEST POSSIBLE Correction

Maximum less than:
6/18
3/10 (0.3)
20/70
6/60
1/10 (0.1)
20/200

3/60
1/20 (0.05)
20/400
1/60 (finger-counting at 1 metre)
1/50 (0.02)
5/300 (12/1200)
No light perception
Undetermined or unspecified

Minimum equal to or better than:

6/60
1/10 (0.1)
20/200
3/60
1/20 (0.05)
20/400

1/60 (finger-counting at 1 metre)

1/50 (0.02)
5/300 (12/1200)

Adapted from International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Geneva, World Health
Organization, 1992
Categories of visual impairment 1 and 2 are referred to as "low vision"; categories 3, 4, and 5 as "blindness"; and category 9 as
"unqualified visual loss." If the extent of the visual field is taken into account, patients with a field no greater than 10 degrees but greater
than 5 degrees around central fixation should be placed in category 3, and patients with a field no greater than 5 degrees around central
fixation should be placed in category 4, even if visual acuity is not impaired.
29
30a
30b

Previous Eye Surgery

Refractive Error
Disorders

Check for the appropriate box whether the patient had already gone an eye surgery previously.
Check the appropriate box for the type/s of Refractive Error the patient has.
Check the appropriate box for the type/s of eye disorders the patient has.

DEPARTMENT OF HEALTH
Integrated Chronic Non-Communicable Disease Registry System

30c
31
32
33

Underlying Causes
Prognosis of Vision Loss:
Prosthetic Device
Type of Cataract

34
35
35a
35b
36
37
38
39
39a
39b
39c
39d
39e
40
40a
40b
40c
40d

Visual Acuity: Pre-operative

Date of Operation
Eye Operated
Name of Surgeon
Type of Cataract surgery
Final Diagnosis: ICD-1O Code
Disposition
Consultant in-charge
License/PRC No.
Address
Landline #
Mobile #
Email Address
Completed By
Address
Landline #
Mobile #
Email Address

41

Date Completed

Date as of July 01, 2013

REC-006-Jul2013-Rev0

Note: If the patient has Cataract, answer field nos. 33 to 36.

Check the appropriate box for the underlying causes of the patients low vision or blindness.
Check the appropriate box for the prognosis of the patients loss of vision.
Check the box corresponding to the prosthetic device use by the patient.
Note: This field will ONLY be answered if the patient is diagnosed with Cataract.
Check the appropriate box whether the patient has Primary or secondary type of Cataract, check for the specific type of cataract the
patient has.
Check the box which eye has best corrected visual acuity.
Write the date of Operation.
Check the box which eye/s has been operated on.
Write the name of the surgeon who performed the operation.
Check the appropriate box for the type of cataract surgery performed in the patient and which eye.
Write the corresponding ICD-10 Code for the patients final diagnosis.
Check the box for the patients disposition.
The position title /designation of the Consultant in-charge must be entered on this portion including the license/PRC No., address and
contact details (landline no., mobile no. and email address).

The position title /designation of the personnel completing the form must be entered on this portion including the address and contact
details (landline no., mobile no. and email address).

Write the date when the form was accomplished must be entered on this portion.