Chief Complaint (CC)
Elicit the patient’s chief complaint or reason for visit.
Past Ocular History (POHx)
- Congenital abnormalities
- Current and past ocular diagnoses
- Cataracts
- Glaucoma
- Age-related macular degeneration
- Amblyopia
- Strabismus
- Past eye trauma/Foreign body removal
- Past eye surgeries
- Surgeon
- Year
- Complications
- Past eye procedures
- Laser
- Indication (e.g. retinal detachment, glaucoma, diabetic retinopathy, etc.)
- Lacrimal damage
- Foreign body removal
- Eye injections (Intravitreal Injections)
- Indication (e.g. diabetes, antibiotics, age-related macular degeneration, etc.)
- Elective procedures
- Cataract removal
- Glaucoma (other than laser)
- Eye prescription (if applicable)
- Contact lens wear
- Contact lens type
- Changes to contact lens
- Wearing contacts over night
- Swimming with contacts
- Optometrist care
Past Medical History (PMHx)
Specifically ask about:
- Asthma
- Autoimmune conditions
- Arrhythmias
- Bleeding disorders
- COPD
- Diabetes
- Hypertensions
- Hyperlipidemia
- HIV
- Sickle trait
- Thyroid conditions
- Coronary artery disease
Family History (FmHx)
- Autoimmune conditions
- Blindness
- Glaucoma
- Macular degeneration
- Ocular and/or pituitary tumour
- Retinal detachment
- Strabismus
- Amblyopia
- Cataracts
- Hypertension
- Coronary artery disease
- Diabetes
Social History (SocHx)
- Occupation
- Driving habits
- Diet
Substance Use History (SubHx)
Specifically ask about:
Ocular Medications (Gtt)
Includes all drops and gels used, make note of:
- Frequency
- Which eye
- Last taken
- Compliance
Medications (Rx)
Gather complete list, including particularly relevant drugs like:
- Amioderone
- Anticoagulants
- Bisphosphonates
- Chloroquines
- Digitalis
- Diuretics
- Immunosuppressants
- Steroids
- Tamsulosin
- Topiramate
- Vitamins for macular degeneration
Allergies
Note allergies and ensure they concord with those listed in the EMR. Make note of the specific reaction and pay particular attention to these relevant allergies:
Review of Systems
Conduct a Review of Systems, keeping other etiologies from your differential in mind.
References
- Bickley LS, Szilagyi PG. Bates' Guide to Physical Examination and History-Taking, 11th ed. Baltimore: Lippincott Williams & Wilkins; 2011.
- Gerstenblith AT, Rabinowitz MP. The Wills Eye Manual: Office and Emergency Room Diagnosis and Treatment of Eye Disease, 6th ed. Baltimore: Lippincott Williams & Wilkins; 2012.
- Harper RA. Basic Ophthalmology, 9th ed. San Francisco: American Academy of Ophthalmology; 2010.