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SUPPLEMENTARY MEDICAL REPORT

1. Name of Patient: RUBY LUPAZ


Diagnosis: Corneoscleral Laceration with Iris Uveal Prolapse, Iris Foreign Body,
Iridodialysis, Traumatic Cataract, Choroidal Detachment, Left Eye

2. Complete detailed history of incident and diagnosis: (please indicate if due to sickness or to
accident): Date of onset, what happened, who he went to for treatment, follow-ups, etc.
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3. Date(s) of patient’s first consultation and follow ups:


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4. Please state your findings and present visual acuity of the affected eye:
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5. Based on patient’s present visual acuity, will patient’s vision improve at a later date? If yes, in
what way will improve? When will improvement occur?
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Pioneer House Makati, 108 Paseo de Roxas, Legaspi Village, Makati City 1229, Philippines
MCPO Box 1437, Makati City, Philippines
Tel: +63 2 812 7777 • Fax: +63 2 817 1461 • www.pioneer.com.ph
6. Please indicate your latest assessment of patient’s vision of the affected eye. (please check 2
for each eye)

Left Eye Right Eye


( ) Partial ( ) Partial
( ) Total ( ) Total
( ) Recoverable/Reversible ( ) Recoverable/Reversible
( ) Irrecoverable/Irreversible ( ) Irrecoverable/Irreversible

Please attach copy of results of diagnostic examinations relative to visual acuity


determination, if there’s any.

DECLARATION

I hereby certify that the above statements and facts are true and that I have not withheld any
material information in connection with this confinement.

____________________ ______________________________________________
Name of doctor, Opthalmologist
Date Physician’s Signature Over Printed Name
Specialization :
License # :
Contact #s:

Pioneer House Makati, 108 Paseo de Roxas, Legaspi Village, Makati City 1229, Philippines
MCPO Box 1437, Makati City, Philippines
Tel: +63 2 812 7777 • Fax: +63 2 817 1461 • www.pioneer.com.ph