Office
Item
Office Use:
text
C0442603 (UMLS CUI [1])
undefined item
Item
Centre:
text
Hospital
Item
i) Hospital / Clinic:
text
C0019994 (UMLS CUI [1])
Date of Notification
Item
ii) Date of Notification:
date
C0011008 (UMLS CUI [1,1])
C0422202 (UMLS CUI [1,2])
Patient Name
Item
1. Patient Name:
text
C1299487 (UMLS CUI [1])
Identification Number
Item
2. Identification Card Number :
text
C1300638 (UMLS CUI [1])
Identification Number
Item
Old IC
text
C1300638 (UMLS CUI [1])
Identification Number
Item
Other ID document No
text
C1300638 (UMLS CUI [1])
Postcode
Item
3. Address (Postcode):
text
C0421454 (UMLS CUI [1])
Town
Item
3. Address (Town/ City)
text
C1555315 (UMLS CUI [1])
State
Item
3. Address (State):
text
C1442792 (UMLS CUI [1])
Date of Birth
Item
4. Date of Birth:
date
C0421451 (UMLS CUI [1])
Age
Item
5. Age at presentation:
text
C0001779 (UMLS CUI [1])
Item
6. Gender
text
C0079399 (UMLS CUI [1])
CL Item
Male (Male)
C0086582 (UMLS CUI-1)
(Comment:en)
CL Item
Female (Female)
C0015780 (UMLS CUI-1)
(Comment:en)
Item
7. Ethnicity
text
C0015031 (UMLS CUI [1])
CL Item
Malay (Malay)
C0024549 (UMLS CUI-1)
(Comment:en)
CL Item
Chinese (Chinese)
C0152035 (UMLS CUI-1)
(Comment:en)
CL Item
Indian (Indian)
C1524069 (UMLS CUI-1)
(Comment:en)
CL Item
Orang Asli (Orang Asli)
C3875078 (UMLS CUI-1)
(Comment:en)
CL Item
Melanau (Melanau)
C3875090 (UMLS CUI-1)
(Comment:en)
CL Item
Kadazan/Murut /Bajau (Kadazan/Murut /Bajau)
C3875081 (UMLS CUI-1)
(Comment:en)
CL Item
Iban (Iban)
C3875071 (UMLS CUI-1)
(Comment:en)
CL Item
Bidayuh (Bidayuh)
C3875070 (UMLS CUI-1)
(Comment:en)
CL Item
Others (Others)
C0205394 (UMLS CUI-1)
(Comment:en)
None
Item
1. Risk factors-None
boolean
C0549184 (UMLS CUI [1])
Diabetes Mellitus
Item
1. Risk factors- Diabetes Mellitus (DM)
boolean
C0011849 (UMLS CUI [1])
Hypertension
Item
1. Risk factors- Hypertension (HPT)
boolean
C0020538 (UMLS CUI [1])
Stroke
Item
1. Risk factors- Past Stroke
boolean
C0038454 (UMLS CUI [1])
Myocardial Ischemia
Item
1. Risk factors- Ischemic Heart Disease (IHD)
boolean
C0151744 (UMLS CUI [1])
Hypercholesterolemia
Item
1. Risk factors- Hypercholesterolemia
boolean
C0020443 (UMLS CUI [1])
Smoking
Item
1. Risk factors- Smoking
boolean
C1519384 (UMLS CUI [1])
Item
If yes,
text
C1519384 (UMLS CUI [1])
CL Item
Current (Current)
C0521116 (UMLS CUI-1)
(Comment:en)
CL Item
Past (Past)
C1444637 (UMLS CUI-1)
(Comment:en)
Myopia right eye
Item
1. Risk factors- Myopia right eye
boolean
C0027092 (UMLS CUI [1,1])
C0229089 (UMLS CUI [1,2])
Item
If yes, myopia right eye
text
C0027092 (UMLS CUI [1,1])
C0229089 (UMLS CUI [1,2])
Code List
If yes, myopia right eye
Myopia left eye
Item
1. Risk factors- Myopia left eye
boolean
C0027092 (UMLS CUI [1,1])
C0229090 (UMLS CUI [1,2])
Item
If yes, myopia left eye
text
C0027092 (UMLS CUI [1,1])
C0229090 (UMLS CUI [1,2])
Code List
If yes, myopia left eye
Cataract surgery
Item
1. Risk factors- Cataract surgery within last 3 months prior to onset of symptoms in the affected eye(s)
boolean
C2939459 (UMLS CUI [1])
Item
If yes, cataract surgery of
text
C2939459 (UMLS CUI [1])
Code List
If yes, cataract surgery of
CL Item
Right eye (Right eye)
C0229089 (UMLS CUI-1)
(Comment:en)
CL Item
Left eye (Left eye)
C0229090 (UMLS CUI-1)
(Comment:en)
driving
Item
i) Are you currently driving, at least once a while?
boolean
C0004379 (UMLS CUI [1])
difficulty driving during daytime in familiar places
Item
If yes, do you have difficulty driving during daytime in familiar places
boolean
C3174290 (UMLS CUI [1])
Item
If no, reason:
text
C0566251 (UMLS CUI [1])
CL Item
never drive (never drive)
(Comment:en)
CL Item
gave up because of poor eye sight (gave up because of poor eye sight)
C3278620 (UMLS CUI-1)
(Comment:en)
CL Item
others (others)
C0205394 (UMLS CUI-1)
(Comment:en)
difficulty reading ordinary print in newspaper
Item
ii) Because of your eye sight, do you have difficulty reading ordinary print in newspaper?
boolean
C3176682 (UMLS CUI [1])
Metamorphopsia
Item
i) Metamorphopsia
boolean
C0271185 (UMLS CUI [1])
Scotoma
Item
ii) Scotoma
boolean
C0036454 (UMLS CUI [1])
Blurred vision
Item
iii) Blurring of vision
boolean
C0344232 (UMLS CUI [1])
Duration of symptoms
Item
iv) Duration of symptoms
text
C0449238 (UMLS CUI [1,1])
C1457887 (UMLS CUI [1,2])
Therapy AMD
Item
v) Previous treatment for AMD:
boolean
C0087111 (UMLS CUI [1,1])
C0242383 (UMLS CUI [1,2])
Item
If yes, what treatment
text
C0087111 (UMLS CUI [1,1])
C0242383 (UMLS CUI [1,2])
Code List
If yes, what treatment
CL Item
PDT (PDT)
C0750653 (UMLS CUI-1)
(Comment:en)
CL Item
Anti VEGF (Anti VEGF)
(Comment:en)
CL Item
PDT + Anti VEGF (PDT + Anti VEGF)
(Comment:en)
CL Item
Intravitral Triamcinolone (Intravitral Triamcinolone)
C0040864 (UMLS CUI-1)
C1554888 (UMLS CUI-2)
(Comment:en)
CL Item
Argon Laser (Argon Laser)
C0392247 (UMLS CUI-1)
(Comment:en)
Item
1. Affected eye
text
C0449642 (UMLS CUI [1,1])
C0015392 (UMLS CUI [1,2])
Code List
1. Affected eye
CL Item
Right eye (Right eye)
C0229089 (UMLS CUI-1)
(Comment:en)
CL Item
Left eye (Left eye)
C0229090 (UMLS CUI-1)
(Comment:en)
CL Item
Both eyes (Both eyes)
C0229118 (UMLS CUI-1)
(Comment:en)
Item
2. Vision right eye
text
C0042789 (UMLS CUI [1,1])
C0229089 (UMLS CUI [1,2])
Code List
2. Vision right eye
CL Item
Unaided (Unaided)
CL Item
With glasses/ Pin hole (With glasses/ Pin hole)
Item
2. Vision left eye
text
C0042789 (UMLS CUI [1,1])
C0229090 (UMLS CUI [1,2])
Code List
2. Vision left eye
CL Item
Unaided (Unaided)
CL Item
With glasses/ Pin hole (With glasses/ Pin hole)
Item
3) Fundus Finding right eye- i) Type of AMD
text
C0242383 (UMLS CUI [1])
Code List
3) Fundus Finding right eye- i) Type of AMD
CL Item
Exudative (Exudative)
C0271084 (UMLS CUI-1)
(Comment:en)
CL Item
Nonexudative (Nonexudative)
C0271083 (UMLS CUI-1)
(Comment:en)
Drusen
Item
3) Fundus Finding right eye- ii) Presence of Drusen
boolean
C0035312 (UMLS CUI [1])
Item
If Yes,
text
C0035312 (UMLS CUI [1])
CL Item
Soft (Soft)
C1720452 (UMLS CUI-1)
(Comment:en)
CL Item
Hard (Hard)
C1719777 (UMLS CUI-1)
(Comment:en)
Geographic Atrophy
Item
3) Fundus Finding right eye- iii) Presence of Central Geographic Atrophy
boolean
C1536085 (UMLS CUI [1])
Pigment Epithelial Detachment
Item
3) Fundus Finding right eye- iv) Presence of Pigment Epithelial Detachment
boolean
C0339546 (UMLS CUI [1])
Subretinal Hemorrhage
Item
3) Fundus Finding right eye- v) Presence of Subretinal Hemorrhage
boolean
C0271049 (UMLS CUI [1])
Disciform Scar
Item
3) Fundus Finding right eye- vi) Presence of Disciform Scar:
boolean
C4476587 (UMLS CUI [1])
Item
3) Fundus Finding left eye- i) Type of AMD
text
C0242383 (UMLS CUI [1])
Code List
3) Fundus Finding left eye- i) Type of AMD
CL Item
Exudative (Exudative)
C0271084 (UMLS CUI-1)
(Comment:en)
CL Item
Nonexudative (Nonexudative)
C0271083 (UMLS CUI-1)
(Comment:en)
Drusen
Item
3) Fundus Finding left eye- ii) Presence of Drusen
boolean
C0035312 (UMLS CUI [1])
Item
If Yes,
text
C0035312 (UMLS CUI [1])
CL Item
Soft (Soft)
C1720452 (UMLS CUI-1)
(Comment:en)
CL Item
Hard (Hard)
C1719777 (UMLS CUI-1)
(Comment:en)
Geographic Atrophy
Item
3) Fundus Finding left eye- iii) Presence of Central Geographic Atrophy
boolean
C1536085 (UMLS CUI [1])
Pigment Epithelial Detachment
Item
3) Fundus Finding left eye- iv) Presence of Pigment Epithelial Detachment
boolean
C0339546 (UMLS CUI [1])
Subretinal Hemorrhage
Item
3) Fundus Finding left eye- v) Presence of Subretinal Hemorrhage
boolean
C0271049 (UMLS CUI [1])
Disciform Scar
Item
3) Fundus Finding left eye- vi) Presence of Disciform Scar:
boolean
C4476587 (UMLS CUI [1])
Item
1. OCT Right eye
text
C0920367 (UMLS CUI [1,1])
C0229089 (UMLS CUI [1,2])
Code List
1. OCT Right eye
CL Item
not done (not done)
Item
If done, findings
text
C0920367 (UMLS CUI [1])
Code List
If done, findings
CL Item
Subretinal fluid (Subretinal fluid)
C2721564 (UMLS CUI-1)
(Comment:en)
CL Item
Pigment epithelial detachment (Pigment epithelial detachment)
C0339546 (UMLS CUI-1)
(Comment:en)
CL Item
others (others)
C0205394 (UMLS CUI-1)
(Comment:en)
specify
Item
Others, specify
text
C1521902 (UMLS CUI [1])
Item
1. OCT left eye +
text
C0920367 (UMLS CUI [1,1])
C0229090 (UMLS CUI [1,2])
Code List
1. OCT left eye +
CL Item
not done (not done)
Item
If done, findings
text
C0920367 (UMLS CUI [1])
Code List
If done, findings
CL Item
Subretinal fluid (Subretinal fluid)
C2721564 (UMLS CUI-1)
(Comment:en)
CL Item
Pigment epithelial detachment (Pigment epithelial detachment)
C0339546 (UMLS CUI-1)
(Comment:en)
CL Item
others (others)
C0205394 (UMLS CUI-1)
(Comment:en)
specify
Item
Others, specify
text
C1521902 (UMLS CUI [1])
Item
2. FFA right eye
text
C0086305 (UMLS CUI [1,1])
C0229089 (UMLS CUI [1,2])
Code List
2. FFA right eye
CL Item
not done (not done)
Item
If done, findings:
text
C0086305 (UMLS CUI [1])
Code List
If done, findings:
CL Item
CNV (CNV)
C0600518 (UMLS CUI-1)
(Comment:en)
CL Item
Scar (Scar)
C0271036 (UMLS CUI-1)
(Comment:en)
CL Item
PED (PED)
C3840040 (UMLS CUI-1)
(Comment:en)
Item
ii) Type of choroidal neovascularization (CNV)
text
C0600518 (UMLS CUI [1])
Code List
ii) Type of choroidal neovascularization (CNV)
CL Item
Classic (Classic)
C1282040 (UMLS CUI-1)
(Comment:en)
CL Item
Minimally classic (Minimally classic)
(Comment:en)
CL Item
Predominantly classic (Predominantly classic)
(Comment:en)
CL Item
Occult (Occult)
C2174712 (UMLS CUI-1)
(Comment:en)
Item
iii) Location of CNV
text
C1515974 (UMLS CUI [1,1])
C0600518 (UMLS CUI [1,2])
Code List
iii) Location of CNV
CL Item
Subfoveal (Subfoveal)
C0442185 (UMLS CUI-1)
(Comment:en)
CL Item
Juxtafoveal (Juxtafoveal)
C1281929 (UMLS CUI-1)
(Comment:en)
CL Item
Extrafoveal (Extrafoveal )
C0442088 (UMLS CUI-1)
(Comment:en)
Item
2. FFA left eye
text
C0086305 (UMLS CUI [1,1])
C0229090 (UMLS CUI [1,2])
Code List
2. FFA left eye
CL Item
not done (not done)
Item
If done, findings:
text
C0086305 (UMLS CUI [1])
Code List
If done, findings:
CL Item
CNV (CNV)
C0600518 (UMLS CUI-1)
(Comment:en)
CL Item
Scar (Scar)
C0271036 (UMLS CUI-1)
(Comment:en)
CL Item
PED (PED)
C3840040 (UMLS CUI-1)
(Comment:en)
Item
ii) Type of choroidal neovascularization (CNV)
text
C0600518 (UMLS CUI [1])
Code List
ii) Type of choroidal neovascularization (CNV)
CL Item
Classic (Classic)
C1282040 (UMLS CUI-1)
(Comment:en)
CL Item
Minimally classic (Minimally classic)
(Comment:en)
CL Item
Predominantly classic (Predominantly classic)
(Comment:en)
CL Item
Occult (Occult)
C2174712 (UMLS CUI-1)
(Comment:en)
Item
iii) Location of CNV
text
C1515974 (UMLS CUI [1,1])
C0600518 (UMLS CUI [1,2])
Code List
iii) Location of CNV
CL Item
Subfoveal (Subfoveal)
C0442185 (UMLS CUI-1)
(Comment:en)
CL Item
Juxtafoveal (Juxtafoveal)
C1281929 (UMLS CUI-1)
(Comment:en)
CL Item
Extrafoveal (Extrafoveal )
C0442088 (UMLS CUI-1)
(Comment:en)
Item
3. ICG right eye
text
C0430879 (UMLS CUI [1,1])
C0229089 (UMLS CUI [1,2])
Code List
3. ICG right eye
CL Item
not done (not done)
Item
3. If done, findings:
text
C0430879 (UMLS CUI [1,1])
C0229089 (UMLS CUI [1,2])
Code List
3. If done, findings:
CL Item
Polyps (Polyps)
C0032584 (UMLS CUI-1)
(Comment:en)
CL Item
Plaque (Plaque)
C0332461 (UMLS CUI-1)
(Comment:en)
CL Item
No Abnormality (No Abnormality)
C1298908 (UMLS CUI-1)
C1704258 (UMLS CUI-2)
(Comment:en)
Item
3. ICG left eye
text
C0430879 (UMLS CUI [1,1])
C0229090 (UMLS CUI [1,2])
Code List
3. ICG left eye
CL Item
not done (not done)
Item
3. If done, findings:
text
C0430879 (UMLS CUI [1,1])
C0229090 (UMLS CUI [1,2])
Code List
3. If done, findings:
CL Item
Polyps (Polyps)
C0032584 (UMLS CUI-1)
(Comment:en)
CL Item
Plaque (Plaque)
C0332461 (UMLS CUI-1)
(Comment:en)
CL Item
No Abnormality (No Abnormality)
C1298908 (UMLS CUI-1)
C1704258 (UMLS CUI-2)
(Comment:en)
Item
a) Diagnosis Right eye
integer
C0011900 (UMLS CUI [1,1])
C0229089 (UMLS CUI [1,2])
Code List
a) Diagnosis Right eye
CL Item
Early AMD (1)
C4231168 (UMLS CUI-1)
(Comment:en)
CL Item
Intermediate AMD (2)
(Comment:en)
CL Item
Advanced AMD: Geographic Atrophy (3)
C1536085 (UMLS CUI-1)
(Comment:en)
CL Item
Advanced AMD: Disciform Scar (4)
C4476587 (UMLS CUI-1)
(Comment:en)
CL Item
Polypoidal choroidal vasculopathy (PCV) (5)
C1504336 (UMLS CUI-1)
(Comment:en)
CL Item
Choroidal Neovascularization (CNV): Active (6)
C4272907 (UMLS CUI-1)
(Comment:en)
CL Item
Choroidal Neovascularization (CNV): Resolved (7)
(Comment:en)
CL Item
Others (8)
C0205394 (UMLS CUI-1)
(Comment:en)
Specify
Item
Others, specify
text
C1521902 (UMLS CUI [1])
Item
b) Diagnosis left eye +
integer
C0011900 (UMLS CUI [1,1])
C0229090 (UMLS CUI [1,2])
Code List
b) Diagnosis left eye +
CL Item
Early AMD (1)
C4231168 (UMLS CUI-1)
(Comment:en)
CL Item
Intermediate AMD (2)
(Comment:en)
CL Item
Advanced AMD: Geographic Atrophy (3)
C1536085 (UMLS CUI-1)
(Comment:en)
CL Item
Advanced AMD: Disciform Scar (4)
C4476587 (UMLS CUI-1)
(Comment:en)
CL Item
Polypoidal choroidal vasculopathy (PCV) (5)
C1504336 (UMLS CUI-1)
(Comment:en)
CL Item
Choroidal Neovascularization (CNV): Active (6)
C4272907 (UMLS CUI-1)
(Comment:en)
CL Item
Choroidal Neovascularization (CNV): Resolved (7)
(Comment:en)
CL Item
Others (8)
C0205394 (UMLS CUI-1)
(Comment:en)
Specify
Item
Others, specify
text
C1521902 (UMLS CUI [1])
Therapy Right eye
Item
a) Right eye: Treatment?
boolean
C0087111 (UMLS CUI [1,1])
C0229089 (UMLS CUI [1,2])
Item
If yes, type of treatment
integer
C0087111 (UMLS CUI [1])
Code List
If yes, type of treatment
CL Item
PDT (1)
C0750653 (UMLS CUI-1)
(Comment:en)
CL Item
Anti VEGF (2)
(Comment:en)
CL Item
PDT + Anti VEGF (3)
(Comment:en)
CL Item
Intravitral Triamcinolone (4)
C0040864 (UMLS CUI-1)
C1554888 (UMLS CUI-2)
(Comment:en)
CL Item
Argon Laser (5)
C0392247 (UMLS CUI-1)
(Comment:en)
CL Item
Other (6)
C0205394 (UMLS CUI-1)
(Comment:en)
specify
Item
Others, specify
text
C1521902 (UMLS CUI [1])
Therapy Left eye
Item
b) Left eye: Treatment? +
boolean
C0087111 (UMLS CUI [1,1])
C0229090 (UMLS CUI [1,2])
Item
If yes, type of treatment
integer
C0087111 (UMLS CUI [1])
Code List
If yes, type of treatment
CL Item
PDT (1)
C0750653 (UMLS CUI-1)
(Comment:en)
CL Item
Anti VEGF (2)
(Comment:en)
CL Item
PDT + Anti VEGF (3)
(Comment:en)
CL Item
Intravitral Triamcinolone (4)
C0040864 (UMLS CUI-1)
C1554888 (UMLS CUI-2)
(Comment:en)
CL Item
Argon Laser (5)
C0392247 (UMLS CUI-1)
(Comment:en)
CL Item
Other (6)
C0205394 (UMLS CUI-1)
(Comment:en)
specify
Item
Others, specify
text
C1521902 (UMLS CUI [1])
Item
Form filled by:
text
C3273494 (UMLS CUI [1])
Code List
Form filled by:
CL Item
Medical Retinal (MR) Specialist (Medical Retinal (MR) Specialist)
CL Item
Vitreo- Retinal (VR) Specialist (Vitreo- Retinal (VR) Specialist)
CL Item
MR or VR fellow (MR or VR fellow)
CL Item
Other specialist (Other specialist)
CL Item
Medical officer (Medical officer)
Item
Form filled by:
text
C3273494 (UMLS CUI [1])
Code List
Form filled by:
CL Item
Medical Retinal (MR) Specialist (Medical Retinal (MR) Specialist)
CL Item
Vitreo- Retinal (VR) Specialist (Vitreo- Retinal (VR) Specialist)
CL Item
MR or VR fellow (MR or VR fellow)
CL Item
Other specialist (Other specialist)
CL Item
Medical officer (Medical officer)