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