Name

Birth Date

Age

Gender

Male Female

Residency

--< Select >-- Cairo Giza Alexandria Port Said Suez Demiatt Dakahlia Sharkia Qalyoubia Kafr Shaikh Gharbia Menouffia Behaira Ismaillia Beni Suif Fayoum Minia Assuit Sohag Qena Asswan Luxor Al Bahr Al Ahmar Al Wadi Al Gaddid Matrouh N. Sinai S. Sinai Other Country

Occupation

Weight (kg)

Height (m)

BMI (Body Mass Index)

Smoking

Yes No

Informed Consent

Diseases

--< Select >-- Rheumatoid Arthritis SLE Systemic Sclerosis JIA Ankylosing Spondylitis Psoriatic arthritis Enteropathic arthritis Gout Pseudogout Polymyositis Dermatomyositis MCTD Sjogren's $ Antiphospholipid $ Adult onset Still's disease Giant Cell Arteritis (GCA) Takayasu Arteritis (TA) Polyarteritis nodosa (PAN) Kawasaki Wegner disease (GPA) Churg Strauss disease (EGPA) Microscopic Polyangitis (MPA) Behcet Syndrome FMF Amyloidosis

Laterality

Unilateral Bilateral Alternating

Location

Anterior Intermediate Posterior Panuveitis

Onset and Course

Acute Chronic Recurrent

Pathology of Uveitis

Granulomatous Non granulomatous

Intraocular pressure

Synechiae Type

Anterior Posterior Annular Total

Treatment

Response

Excellent Good Poor No response

Location

Anterior Posterior Panscleritis

Pathology of Anterior Scleritis

Diffuse Nodular Necrotizing with inflammation Necrotizing without inflammation

Treatment

Response

Excellent Good Poor No response

Type

Ulcerative Non Ulcerative

Site

Central Peripheral

Vascularization

Vascularized Non vascularized

Treatment

Response

Excellent Good Poor No response

Pathology

Ischemic Inflammatory Neuroretinitis Optic disc edema Cupping

Results of colour vision testing

Pupillary reaction

Positive Negative

History of previous ocular surgery

Yes No

History of previous ocular procedures

Yes No