|
Use OnPatient HPI
|
Enter HPI
|
|
Telehealth Visit?
|
|
|
Telehealth App Used:
|
|
|
Patient Location:
|
Consent Obtained:
|
|
What the reason for your appointment?
|
Pt is presenting for... freewrite
|
|
|
HPI Freewrite
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Notes
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Which eyes are affected?
|
How long has this been bothering you?
|
|
What symptoms are bothering you?
• • •
|
If other symptoms are bothering you, please list.
|
|
How badly is this bothering you?
|
How frequently is this bothering you?
|
|
Check situations where your symptoms are worse.
• • •
|
If there is another situation in which you are very bothered by your vision, please list it.
|
|
2EE statements
• • •
|
HPI Freewrite
|
|
Previous Treatment
|
Notes Freewrite
|
|
Diabetic?
|
How long have you been diabetic?
|
|
What do you use to treat diabetes?
|
What was your last hemoglobin A1c?
|
|
Prostate Meds?
|
What prostate meds?
|
|
Using blood thinners?
|
Which blood thinners?
|
|
History of long-term steroid use?
|
Please describe steroid use.
|
|
History of significant eye trauma?
|
Please describe the trauma.
|
|
Allergy to latex?
|
What is your reaction?
|
|
Allery to betadine (povidone-iodine)?
|
What is your reaction?
|
|
Have any eye conditions (i.e. glaucoma, macular degeneration)?
|
Please list. (If multiple, separate with commas.)
|
|
Use any eye drops regularly (OTC or Rx)?
|
Please list drops. (If multiple, separate with commas.)
|
|
Had any prior eye surgeries (including LASIK)?
|
Please list. (If multiple, separate with commas.)
|
|
Currently wear contact lenses?
|
What type of contact lens?
|
|
|
CTL Comments
|
