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Ref. by
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PCP
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Cc/History:
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Location
• • •
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Timing
• • •
|
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Vision changes in
• • •
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Context
• • •
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VA
• • •
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Distortions
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Duration
• • •
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Quality
• • •
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Epiphora
• • •
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Tobacco
|
If quit, how long?
|
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Diabetes
|
|
|
Heme A1C
|
BS Level
|
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|
|
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Technician:
• • •
|
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Reviewed by MD/OD doctor
|
