IP LogBook
Drew Thompson MCOptom DipTp(IP) FBCLA
Date
-
Month
-
Day
Year
Date
Is this patient from?
T&H Optometrists
Blackpool Victoria Hospital
Optix ID / Hospital Number
*
Diagnosis
*
Known Allergies (If yes detail below)
Yes
No
Other Information
Drug Prescribed?
*
Dose?
*
Which eye?
*
Please Select
Right Eye
Left Eye
Both Eyes
Oral
Frequency?
*
Please Select
OD
BD
TDS
QDS
6x
2 Hourly
Hourly
PRN
Amount prescribed?
*
Please Select
One week
Two weeks
One month
Three months
Ongoing
Referred onward?
Yes
No
Add more drugs here...
Drug Prescribed?
Dose?
Which eye?
Please Select
Right Eye
Left Eye
Both Eyes
Oral
Frequency?
Please Select
OD
BD
TDS
QDS
6x
2 Hourly
Hourly
PRN
Amount prescribed?
Please Select
One week
Two weeks
One month
Three months
Ongoing
Drug Prescribed?
Dose?
Which eye?
Please Select
Right Eye
Left Eye
Both Eyes
Oral
Frequency?
Please Select
OD
BD
TDS
QDS
6x
2 Hourly
Hourly
PRN
Amount prescribed?
Please Select
One week
Two weeks
One month
Three months
Ongoing
Drug Prescribed?
Dose?
Which eye?
Please Select
Right Eye
Left Eye
Both Eyes
Oral
Frequency?
Please Select
OD
BD
TDS
QDS
6x
2 Hourly
Hourly
PRN
Amount prescribed?
Please Select
One week
Two weeks
One month
Three months
Ongoing
Drug Prescribed?
Dose?
Which eye?
Please Select
Right Eye
Left Eye
Both Eyes
Oral
Frequency?
Please Select
OD
BD
TDS
QDS
6x
2 Hourly
Hourly
PRN
Amount prescribed?
Please Select
One week
Two weeks
One month
Three months
Ongoing
Drug Prescribed?
Dose?
Which eye?
Please Select
Right Eye
Left Eye
Both Eyes
Oral
Frequency?
Please Select
OD
BD
TDS
QDS
6x
2 Hourly
Hourly
PRN
Amount prescribed?
Please Select
One week
Two weeks
One month
Three months
Ongoing
Submit
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