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Office Visit
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Dilation Exam
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Location
• • •
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Location Comments
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Quality
• • •
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Quality Comments
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Severity
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Severity Comments
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Duration
• • •
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Duration Comments
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Onset / Timing
• • •
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Onset Comments
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Context
• • •
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Context Comments
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Modifying Factors
• • •
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Modifying Factors Comments
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Associated Symptoms
• • •
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Associated Symptoms Comments
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Previous Treatment
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Pupils PERRLA
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Pupils
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NCT/GAT
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Pretesting Docs
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OD/OS PRESSURE
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Time
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w/ correction?
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OD VA:
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PINHOLE OD
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OS VA:
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PINHOLE OS
|
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Ant seg Normal OU? lid,con,k,ac,iris,lens,vit
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Anterior Segment comments
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LIDS OD
• • •
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lids od
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LIDS OS
• • •
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lids os
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CONJUNCTIVA OD
• • •
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conj od
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CONJUNCTIVA OS
• • •
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conj os
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Iris OD
• • •
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Iris od
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Iris OS
• • •
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Iris os
|
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Lens OD
• • •
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Lens OD
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Lens OS
• • •
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Lens OS
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Vitreous OD
• • •
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Vit OD
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Vitreous OS
• • •
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Vit OS
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NaFl drops?
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CORNEA OD
• • •
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cornea od
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CORNEA OS
• • •
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cornea os
|
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OD ANGLES
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OS ANGLES
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Post Seg Normal OU? ONH, macular, vessel
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Posterior Segment comments:
|
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Dilated?
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|
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Drops used
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Time
|
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OD Cup to Disc ratio
• • •
|
OD: C/D
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OS Cup to Disc ratio
• • •
|
OS C/D
|
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OD Optic Nerve
• • •
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OD Optic Nerve
|
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OS Optic Nerve
• • •
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OS Optic Nerve
|
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OD Macula
• • •
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OD Macula
|
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OS Macula
• • •
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OS Macula
|
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OD Vessels
• • •
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OD Vessels
|
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OS Vessels
• • •
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OS Vessels
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OD Periphery
• • •
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OD Periphery
|
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OS Periphery
• • •
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OS Periphery
|
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Assessment
• • •
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A/P comments
|
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Plan
• • •
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