INSTRUCTIONS

  1. This form may be completed by either the prescriber or consultant ophthalmic professional. This form must be signed by the prescriber and faxed to SHARE for every patient at baseline (within 4 weeks of starting SABRIL).
  2. For patients formally exempted from visual assessment due to blindness or irreversible neurological condition, subsequent forms are not required to be submitted.
  3. For all other patients, follow-up assessment forms are required to be submitted at least every 90 days while the patient is taking SABRIL and approximately
    3-6 months after discontinuation.
  4. The diagnostic approach should be individualized according to each patient and/or clinical situation. Although attempts should be made to assess visual acuity and visual fields, no specific tests are required.
  5. All fields must be completed.
Completed forms should be faxed to the SHARE Call Center at 1-877-742-1002.

SECTION ONE: Patient Profile

Name: *   Sex: DOB:
First, Middle, Last mm/dd/yyyy
Address * City * State * ZIP *
Patient currently on Sabril: *

SECTION TWO: Consultant Ophthalmic Professional*

Was an ophthalmic professional consulted? *
Ophthalmic Professional Name (First, Middle Initial, Last)
NPI #     Ophthalmic Professional Address
City State ZIP Phone
xxx-xxx-xxxx

I (ophthalmic professional's name, printed), , attest that the vision assessment as indicated below was conducted.
Signature:
 
Date:
No Stamped Signature mm/dd/yyyy

*With expertise in visual field interpretation and the ability to perform dilated indirect ophthalmoscopy of the retina.

SECTION THREE: Ophthalmologic Assessment

1. Was an ophthalmologic assessment conducted? * Yes No
mm/dd/yyyy
If NO, for which reason was an ophthalmologic assessment not conducted?
Patient is blind (Checking this box exempts patient from follow-up assessments)
Patient's general neurological condition precludes the need for visual assessment


Patient's medical condition precludes safe visual assessment (please explain)



Other (please explain)
If assessment occurred more than 1 month after the due date, please indicate the reason:
Patient's financial/reimbursement situation
Transportation issues
Scheduling conflicts
Other (please explain)

2. Was a best-corrected visual acuity evaluation conducted? *
If yes, please indicate the results: Left eye / Right eye /

3. Were the visual fields assessed? *
Was confrontational testing conducted? *

Which method of visual field testing was used? *(check all that apply)
Kinetic: Goldmann, V4e isopter
Kinetic: automated (SSA-kinetic test from Humphrey or Octopus perimeter menu: III4e isopter)
Static automated threshold perimetry (to at least 60°)
Other
Was this the same technique as used for baseline?*
Was the test deemed reliable?*
Comment


Please indicate the results by providing the estimated visual field extent in:
      Temporal field ODdegrees from center
      Temporal field OSdegrees from center
      Nasal field ODdegrees from center
      Nasal field OSdegrees from center

4. Other types of testing performed (Check all that apply. No specific tests are required and this question may be left blank.)
None
Indirect ophthalmoscopy/Fundoscopy
OCT
ERG
Other

SECTION FOUR: Prescriber Agreement and Signature

I (prescriber's name, printed), agree that I have received and reviewed the vision assessment results for my patient and will submit this form to the SHARE Call Center.
Signature:
 
Prescriber's NPI #: Date:
No Stamped Signature mm/dd/yyyy

If formal perimetry or OCT was conducted, please attach a copy of the visual field recordings.