EUROPEAN REGISTRATION FIREWORKS EYE INJURIES - 2017/2018

 

1DOCTOR/ PRACTICE DETAILS
Name Ophthalmologist/ Practice Email Ophthalmologist/ Practice Country
2PATIENT DETAILS
Date of birth patient Gender patient
3INCIDENT DETAILS
incident date Caused by (Il)legal fireworks? Type fireworks
4INJURY and TREATMENT
Number of visits to the clinic eyes affected if both eyes are affected please specify for both
OD type of injury OS
NO PERMANENT DAMAGE
PROBABLY LOSS OF FUNCTION
CERTAINLY LOSS OF FUNCTION
TOTAAL LOSS SIGHT
LOSS OF BULBUS
OD therapy OS
NONE
OINTMENT and/or DROPS
RINSING
EXAMINATION UNDER ANESTHESIA
SUGERY REQUIRED
FURTHER TREATMENT NEEDED AFTER SURGERY

PLASTIC SURGERY

is a plastic surgeaon involved in treatment?

OTHER INJURIES BESIDES EYE(S)

please specify:
5SUBMIT DATA
date remarks

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