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4 HPI: Loc., Since, Bad?, When,
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Last Eye Exam
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NEUROLOGIC
• • •
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MHx/FHx/Meds/Allergies REVIEWED
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CURRENT ILLNESS
• • •
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Additional Info
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EYE PROBLEMS
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EYE PROBLEMS
• • •
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GENERAL/CONSTITUTIONAL
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General/ Constitutional
• • •
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Ear, Nose, Throat
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EAR, NOSE, THROAT
• • •
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CARDIOVASCULAR
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CARDIOVASCULAR
• • •
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RESPIRATORY
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RESPIRATORY
• • •
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GASTROINTESTINAL
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Gastrointestinal
• • •
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Genital/Kidney/Bladder Problems
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Genital Kidney bladder
• • •
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FEMALE; Pregnant?
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FEMALES; Nursing?
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Muscles, Bones, Joints
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MUSCLES, BONES, JOINTS
• • •
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SKIN
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SKIN
• • •
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NEUROLOGICAL
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NEUROLOGICAL
• • •
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PSYCHIATRIC
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PHYSCHIATRIC
• • •
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ENDOCRINE
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ENDOCRINE
• • •
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BLOOD / LYMPH
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BLOOD / LYMPH
• • •
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ALLERGIC / IMMUNOLOGIC
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Allergic / immunologic
• • •
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Additional Comments
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Family MHx
• • •
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Family Member
• • •
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Drink Alcohol?
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How Much Alcohol
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Smoker?
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How much
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Does Vision Limit Activities?
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activities limited by vision
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VAsc @ Distance OD
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VAsc @ Distance OS
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VAcc @ Distance OD
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VAcc @ Distance OS
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Old SRX LENSOMETRY OD / OS
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AUTOKERATOMETRY OD / OS
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AUTOREFRACTION OD / OS
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SUBJECTIVE REFRACTION OD
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VA OD
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SUBJECTIVE REFRACTION OS
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VA OS
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ADD (+)
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NEAR VA OU
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WET/CYCLO OD/OS
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Cyclo VA OD
• • •
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BINOCULAR BALANCED FINAL SRX
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Cyclo VA OS
• • •
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NRA(+)/PRA(-)
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NPC
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PHORIA DIST
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PHORIA NEAR
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CVF
• • •
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EOM
• • •
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PUPILS
• • •
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STEREOVISION
• • •
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COVER TEST
• • •
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COLOR VISION (Ishihara)
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PRE-AURICULAR NODE; Palpable?
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PA Comments:
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OCULAR ADNEXA
• • •
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OA Comments
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EYELIDS/LASHES
• • •
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Lids/Lashes Comments
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SCLERA/EPISCLERA
• • •
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S/E Comments
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CONJUNCTIVA
• • •
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Conj Comments
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CORNEA
• • •
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Cornea Comments
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IRIS
• • •
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Iris Comments
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ANTERIOR CHAMBER
• • •
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AC Comments
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ANGLE ESTIMATE
• • •
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LENS
• • •
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LENS
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FOVEAL REFLEX OU?
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MACULA
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Macula Comments:
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VITREOUS
• • •
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Vitreous Comments
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POSTERIOR POLE
• • •
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Post Pole Comments
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VASCULATURE
• • •
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Vasculature Comments
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OPTIC NERVE
• • •
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ONH Comments
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PERIPHERY
• • •
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Periphery Comments
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DILATION
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Dilation Refusal SIG
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C/D Ratio OD
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C/D Ratio OS
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IOP (Goldmann) OD/OS
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IOP (Tonopen) OD/OS
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Anterior Seg / Fundus Drawing
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