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HPI
|
|
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Diabetic
• • •
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Normals
• • •
|
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Symptoms
• • •
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Cataracts
• • •
|
|
MODIFIERS
• • •
|
Things that help
• • •
|
|
|
|
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Floaters / Flashes
• • •
|
Chalazion / Eyelid
• • •
|
|
Eye Drops
• • •
|
Double vision
• • •
|
|
POSITIVE ROS
• • •
|
NEGATIVE ROS
• • •
|
|
|
|
|
|
HPI
|
|
|
|
|
|
|
|
|
|
|
History
|
|
|
Allergies to medications?
• • •
|
Allergies
|
|
|
|
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Occupation / Marital status
|
|
|
Medical Problems
• • •
|
Past Medical History
|
|
Medications
• • •
|
Medications
|
|
|
|
|
Family History
• • •
|
Family History
|
|
|
|
|
Tobacco Use?
|
Alcohol Use?
|
|
Drug Use?
|
Explain:
|
|
|
|
|
Past Ophthalmic History
|
Eye Meds
• • •
|
|
|
Ophthalmic Meds
|
|
|
|
|
ROS WNL?
|
Explain:
|
|
Eyes
|
Neuro (strokes, etc)
|
|
Constitutional (weight loss, fever)
|
Muscuoloskeletal (arthritis)
|
|
ENT
|
Heme/lymph (prostate, infections)
|
|
Cardiovascular
|
Allergies/Hay fever
|
|
Respiratory
|
Endocrine (thyroid, DM2)
|
|
GI
|
Integumentary (dermatitis)
|
|
Psych
|
Genitourinary
|
