Premature Retinopathy Assessment Form
Please complete this form to assess risk factors and symptoms related to premature retinopathy in infants.
Infant's Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Gestational Age at Birth (weeks)
*
Birth Weight (grams)
*
Contact Email Address
example@example.com
Parent/Guardian Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Risk Factors Assessment
*
Rows
Present
Absent
Oxygen therapy
1
2
Sepsis
3
4
Blood transfusion
5
6
Mechanical ventilation
7
8
Multiple births
9
10
Intraventricular hemorrhage
11
12
Retinopathy Symptoms Observed (select all that apply)
*
Abnormal eye movements
White pupils (leukocoria)
Strabismus (crossed eyes)
No symptoms observed
Other (please specify)
Severity of Retinal Changes (as observed by examiner)
*
No change
1
2
3
4
Severe change
5
1 is No change, 5 is Severe change
Screening Method Used
*
Indirect ophthalmoscopy
Digital retinal imaging
Other (please specify)
Date of Assessment
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Examiner's Comments or Observations
Examiner's Signature
*
Submit Assessment
Submit Assessment
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