<p> Shropshire Telford and Wrekin Clinical Commissioning Group Clinical Commissioning Group PEARS – First Attendance Follow Up Patient’s Details Optometrist / Practice First name: Optometrist: Last name: OPL number: DOB: Practice: NHS number: Address: Phone: </p><p>Patient’s GP Phone: GP name: Mobile: Practice: Email: U18 18-30 31-45 Age Group 46-60 61-75 Over 75 Ethnicity Code* *Optional Smoker? Yes N Phone: o Referral Information Date referred: Date seen: Referred by GP Pharmacist Optometrist Patient Acute vision problem Eye pain / discomfort Headaches Other (specify): Reason for referral Flashes/floaters Red eye Trauma Patient’s Declaration and Consent I confirm I have had a PEARS first examination / follow up. I consent to the results of these tests being collected for the purpose of CCG audit and ensuring best practice amongst optometrists. I consent to information being exchanged between the Hospital Eye Service, my General Medical Practitioner and my optometrist. Signature Date</p><p>Right Right Yes Diagnosis & Findings Distance VA Tonometry Dilated Left Left No Anterior Lids / lashes Tears Conjunctiva Cornea Other Posterior Macula Retinal Vascular Retinal Detachment PVD Other Uveitis Anterior Episcleritis Scleritis Other Other Field defect Diplopia Systemic Other Resolved Lid lumps Conjunctivitis Diplopia Other Further details:</p><p>Action Taken Advised Follow up arranged? Education Making Every Sight test Done Yes No Signposting Contact Count Not Required In weeks / months Smoking Cessation</p><p>Medication None Recommended Supplied by: Dry Eye Optometry Practice Pharmacy – Bought OTC Allergic Conjunctivitis GP Pharmacy – Written Order Infective Conjunctivitis Pharmacy – PEARS Medication Form</p><p>Referral Refer to GP Refer to HES Refer Emergency No Referral</p><p>Comments</p><p>I confirm I have conducted the PEARS examination in accordance with the protocol. I understand that the CCGs will monitor all referrals and may from time to time ask to see the records of patients examined under the scheme. Signature Date</p>