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The Philippine National Registry for Ethambutol-related Toxic Neuropathy
 
 
 
 
 
 

PNR-ETON Follow-up FORM

A. GENERAL INFORMATION
1. Eye MD/Reporter Name
2. Patient Name
3. Date of Ff-up

B. ANTI-TB THERAPY
Component Compliance while on Treatment(check one) Total Duration of
Tx(in weeks)
4. ALL Anti-TB Medications...or specify:
4a. Ethambutol (EMB)
4b. Isoniazid (INH)
4c. Rifampicin (RIF)
4d. Pyrazinamide (PZA)

C. EYE EXAMINATION
 
OD
OS
 
5. Best Corrected Distance Visual Acuity on 1st Consult
 
6. Visual Field Defect
others
7. Color Vision (Ishihara Color Plates)
out
out
8. Other Color Tests (please specify )
 
9. Fundus Appearance
others
10. Concomitant Eye Disease/Diagnosis
others

D. ANCILLARY PROCEDURES
PROCEDURE
RESULTS
11. Neuro-imaging (CTscan/MRI)
12. Others (please specify )

Thank you for your continuing support!