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Hydroxychloroquine (Plaquenil) Evaluation

Patient Name Referring Physician Consultant Optometrist Date Plaquenil dose / / mg Number of years taking HCQ Patients Weight Estimated Lean Weight Fundus exam Normal Other lbs. lbs. D.O.B.

Acuity Right 20/_____ Left 20/_____

Macular Visual Field Testing (10-2)

Normal

Other

Additional Testing

Recheck

Annually

Other

Comments:

Thank you very much for entrusting us with the eye care of your patient.

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