|
|
Ref. by
|
|
|
PCP
|
|
Cc/History:
|
|
|
Location
|
Timing
|
|
Vision changes in
|
Context
• • •
|
|
VA:
|
Distortions
|
|
Duration
|
|
|
Quality/ Severity
|
|
|
Epiphora
• • •
|
|
|
Heme A1c
|
|
|
BS Level
|
Technician:
• • •
|
|
|
Reviewed by MD/OD doctor
|
|
|
|
|
|
|
|
|
|
|
|
|
|
POH
• • •
|
Past Surgery
|
|
Other POH
|
|
|
Ocular Meds
• • •
|
|
|
Other Ocular Meds
|
LASER
• • •
|
|
Flomax (Tamsulosin)
|
PMH general diseases
|
|
Diabetes
|
|
|
Hypertension
|
|
|
Thyroid disease
|
|
|
ROS/Medical Hx
• • •
|
|
|
|
|
|
|
Family Hx:
• • •
|
|
|
Smoking
|
|
Occupation:
|
ETOH
|
|
|
Drugs
|
